Patient Education Directed at Reducing LBP Disability

James Rainville, MD

New England Baptist HospitalDepartment of PM&R

Harvard Medical SchoolBoston, MA

Important Factor in Back Pain• Patient thoughts

Fear Avoidance Beliefs

• Cognitive schemes that links back pain and disability

Waddel G et al. A fear avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157-68

Fear• Emotional response generated from

dangerous or painful experiences (Potential useful survival mechanisms)– Classic conditioning - prior experiences that

stimulate back pain can re-elicit a fear response to similar exposures

– Learned through vicarious exposure - observing others with back pain (modeling)

Field AP. Fear information and the development of fears during childhood: effects on implicit fear responses and behavioral avoidance. BehavResTher2003;41:1277-93

Askew C  Field AP. Vicarious learning and the development of fears in childhood. Behav Res Ther (2007 Nov) 45(11):2616-27

Avoidance behaviors based on fear

• Fear of movements and physical activities that results in reluctance to engage in normal physical activities

Beliefs

• Convictions of the truth of propositions without their verification

• Subjective, mental interpretations derived from perceptions, reasoning or communications

Everyone has beliefs about their back pain!

• Processes responsible for back pain• Structural soundness of their spine• Risk to the spine associated with physical

activities

• Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157-68.

Source of back pain beliefs

• Interpretations of past experiences• Friends, family, acquaintances• Societal attitudes• Media• Literature• Internet

Back pain providers

• Exhaustive variety of rival theories insinuations different musculoskeletal, neurological and psychological pathologies as the source of back pain

• Each with different implications for prognosis, treatment, and prevention

• Each enhances or challenges patients’ fears and belief

Beliefs about back pain

• Directly influence decision to perform or avoid activities– Personal– Recreational– Vocational

• Underpin back pain related disability

Fear Avoidance Beliefs QuestionnaireFABQ - Activities

1. Physical activities make my pain worse.

2. Physical activities might harm my back.

3. I should not do physical activities which (might) make my pain worse.

4. I cannot do physical activities which (might) make my pain worse.

Completely Completely

Disagree Agree

0 1 2 3 4 5 6

Waddel G et al. A fear avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157-68

Fear avoidance beliefs have a wide distribution

• Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk in back pain and ADL in the General Population. Pain 2002;99:485-91

0

5

10

15

20

25

0 6 12 18 24

FAB-A Scores

freq

uenc

y %

Classification of Fear Avoidance

• Affective avoiders– Profound distress,

excessive pain inhibition of movements, irrational fear of back pain

Pincus T, Smeets RJ, Simmonds MJ, Sullivan MJ, The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain 2010;26:739-46.

Classification of Fear Avoidance

• Learned pain avoiders– Activities are

painful and therefore a conscious choice is made to avoided those activities

Classification of Fear Avoidance

• Misinformed avoiders– Beliefs encompass

ongoing reasoning and are therefore amenable to new education and experiences

Most Patients Endorse the Injury Model of Back Pain

• Abnormal/asymmetrical stresses and strains, repetitive movements acceleration spine degeneration and can cause abrupt failure of spinal structures.

Injury Model

• “Injury Model” is engrained in our societal wisdom about low back pain

• Engrained in beliefs of most medical providers (PCPs, PTs, Spine Specialists)

Implications of Injury Model

• Injury can be prevented– Activity avoidance may lead

to injury avoidance– Work restrictions may reduce

risk– Ergonomic interventions may

reduce risk

• Assuming a disability lifestyle reduces risk

Evidence to Refute Injury Model

• 70 % of people cannot identify anything associated with onset of symptoms– Hall, Spine 2005

Inciting Event 37.7%

Spontaneous 62.3%

Heavy lifting 6.5%

Light lifting 2%

Non-lifting activity

26%

Non-exertionOccurrences 2%

Physical trauma (1.3%)

Onset of Sciatica (disc herniation)

Suri, ISSLS 2009

Evidence to Refute Injury Model

• Ergonomic interventions have not produced substantial reduction of back/neck injuries– Grooten, Work, 2007– Hartvigsen, Occ Envir Med 2005

• Activity avoidance offers no advantage over continued activities– Hagen, Spine 2002

• Work restrictions do not lead to greater RTW success– Hall, Spine 1994

Alternative Explanation for Spine Degeneration

Spine degeneration results from inadequate cell function.

• Evidence-bases, biological and epidemiological explanation for spinal degeneration & low back pain

Etiology of Disc Degeneration

• Apoptosis - Genetically programmed cell death

• Cell mediated changes in disc structures

AnnularCells

NuclearCells

Predictors of Disc Degeneration

• Heritability – Lumbar spine - 74%– Occupation – 1%

• Sambrook, Arthritis Rheum 1999

• Genetic Research– Trp3 allele on COL9A3 gene– TaqI tt genotype of the Vitamin

D receptor gene– 5A5A and 5A6A genotypes of

metalloproteinase-3 gene

Implications of Cellular Explanation of Spinal Degeneration

• Spine degeneration is inevitable (part of aging).

• It does not matter what you do, your spine will degenerate as you age!

• Activity restrictions are futile.

Address the Importance of Symptoms

Most patients (and health care providers) believe that LBP is important!

• Pain is produced by a pain generator in the spine

Implications of Pain Generator Theory

• Pain will persist until the pain generator is identified and successfully treated

Implications of Pain Generator Theory

• It is advisable to avoid activities that produce pain

Alternative explanation for back pain symptoms that offers a

patient oriented solution

Uncouple Degeneration and Back Pain

• MRIs of Adults without Symptoms – 4 out of 5 adults have

disc bulges, protrusion and herniation

– 1 in 25 adults have ruptured discs

• Jensen, NEJM 1994• Weishaupt, Radiology 1998• Stadnik, Radiology 1998

Uncouple Degeneration and Back Pain

• 20% of the population never experience back pain

• Acute back pain usually goes away even though the degeneration that produced it does not

Back Pain is a Neurological Phenomena

• Dynamic interaction between the spine and the central nervous system

Back Pain• Neurological Phenomenon

– Low threshold pain -

pain that is generated by stimuli that are not harmful, nor of adequate intensity to stimulate the pain neurons when they are functioning normally

Low pain threshold is not

low pain tolerance!!!

Manifestations of Low Threshold Pain

• Mechanical allodynia – pain produced by non painful stimulus

• Kinesiodynia – pain produced by harmless movements, positions and physical activities

Low threshold pain is a pain processing problem.

Low Threshold Pain Influences, and is Influenced by the Brain

• Pain gets our attention and causes us to worry

• Chronic pain is discouraging

• Cognitive / emotional factors lower the threshold to painful stimuli Salomons et al, J of Neuroscience, 2004

Low threshold pain is biologically useless!

• Neurological dysfunction

• No protective function

• Because pain inducing activities are harmless, we can choose to continue activities in the presence of pain without doing harm

New knowledge must offer a solution!

• Pain threshold is trainable – repeat exposure to stimulus can diminish the pain response to that stimulus

Recovery from Back Pain

• Spine degeneration does change

• Neurological system adapts to degeneration– Pain neurons

recalibrate to the degenerative spine and return to their quiet state

Neurological adaptation is induced by stimulating the back pain in tolerable ways.

• Stay physically active through tolerable pain

• Be consistent with physical activities– Make small changes

• Stretch the back daily– Work the rust out

• Exercise the back– Get the back strong again

• Keep Working– Make some money while you are in

pain

Exercise

• Exercise performed in a quota-based manner (not dependent on pain) may aid the pain-desensitization process

• Exercise may also function as a educational tool to improve pain cognition– Improve confidence for

physical activities– Lessen fears and concerns

Intensive Spine Rehabilitation“Operationalize Reactivation”

Quality Assurance Database

141 Patients with CLBP

Duration of LBP > 12 monthsBack pain > 6Oswestry Disability Index >40 Compliant (80%)

Improved Pain

4.7

8

012345

6789

10

Evaluation Discharge

Pai

n

N=141

Improved Disability

33

54

0102030405060708090

100

Evaluation Discharge

Osw

estr

y

N=141

Change Cognition through Education

“We are not responsible for what patients believes before they come to our office.”

“We are responsible for what they believe when they leave.”

Aage Indahl, Spine 1995