- Back Problem: Activity limitation due to back or related leg symptoms
This example include:
Treatment: Maintain or build comfortable activity tolerance.
Patients expect us to simply fix the problem, but unfortunately that is NOT reality. Can we prevent it? Can we specifically diagnose the source of symptoms in most patients? The few we can diagnose how much can we change the natural history greatly for the better? Are the risks of our most expensive procedures insignificant? The answer to all these questions is unfortunately NO! We have to build a firm foundation to avoid outcomes costly to the patient, their family and our society.
Back problems impact us all directly or indirectly as the most expensive musculoskeletal problem, industrial injury and most common cause of disability under 45 years of age. Virtually everyone living to age 50 experiences back problems. It is the extremely rare after 50 years of age to lay a driveway by hand over the weekend then play basketball on Monday as we expected at 18 years of age.
The working person, who moves furniture, carries cement bags or rapidly unload less heavy objects, pays most directly. Livelihoods and family futures are commonly threatened by a back problem. Back symptoms similarly slow down housewives and farmers, trapped as there is no one else to do their daily chores. Similar activity limitations inconvenience the lawyer, administrator or physician by perhaps interfering with a racquetball game or tennis match without impacting income or future. The professional along with the rest of us pays indirectly for back problems in the both costs of goods and services we purchase as well as taxes we pay. The reality is that few people avoid the burden due to the inherent inability of the back to be comfortably used as a crane at work until age 65.
Where does medical care fit in? For decades the question of care being optimal back problems. In the United States we have the world's highest back operation rate and a nine-fold difference in the use of different evaluation and treatment techniques in different geographical areas. Newer technology, non-data based care, competition and expensive compensation have fueled rather than decreased costs. Scientific information gleaned in the last decade found patients' back problems worsened by confusing hypotheses about diagnoses, treatment and etiology. Relying upon less than Reliable Science can foster detrimental activity fear / avoidance, compound non-physical pressures and increase the administrative burdens for both the patient and the care-giver.
The definitions and resultant treatment considerations in this handbook are derived from the AHCPR Low Back Guideline systematic review of the literature consisting of searching over 11,000 articles, of which evidence was sought in 4,600 of those articles through an evidence table methodology to find and glean reliable data from now over 400 articles (US Department of Health and Social Services AHCPR Guideline # 14 and subsequent efforts by dedicated members of the Panel). In 2001 a publication validated the reliability of the original Guideline finding and recommendation statements. The clinician's use of the enclosed information stresses sound reliable science to avoiding experimental, speculative or proven ineffective medical recommendations. There are true back emergencies, but they are rare without warnings detectable in a non-technical history and physical examination. The patient is the decision maker. Thus, the patient deserves the clearest understanding possible of what medical science finds and does not find reliable to make the best possible decision. The Initial examination and the scientific literature form the foundation for the clinician to build credibility and avoid undue consternation should someone seek either an excuse or blame for a lack of progress. This brings us to some of our most difficult patients and our greatest challenges.
In addition to a reasonable approach to physical treatment I tried to provide the means to survive in the injury contests. This can unduly emotionalize the patient's life and decision-making process making care even more difficult. Caring for the patient is helping the patient cope with symptoms, fears of activity and the frustrations that can lead cloud a reasonable assessment of risky procedures. Being able to assure the patient that he or she "deserves the most dependable recommendations medical science provides" is not always easy considering the plethora of used care salesman approaches to back care. While not easy, assurance is paramount to the clinician efforts to help keep patients active to avoid debilitation or build comfortable activity tolerance in the few already debilitated. A practical approach first seeks potentially serious conditions to allow a 2 stage mantra "Good News- Nothing Serious!" and "Normal Activity As Soon As Possible". Activity can avoid disability and speed recovery but also set the stage for dealing with difficult non-physical issues for those slowest to recover to avoid patient responses akin to "It didn't work, Doc! Now what are you going to do?". Be a professional who helps the patient cope with both the potential physical and the non-physical obstacles blocking successful return to work. Part of care is helping the patient distinguish between reliable science and "hope so, think so" hypotheses when patients are lured to seek a dangerous cure without evidence of efficacy.
The literature now arms the clinician sufficiently to set reasonable expectations and to help patients avoid both physical and non-physical pitfalls. As reimbursement shrinks, reliable data helps the clinician be more effective and be sufficiently efficient to reduce the sting of having to see another back patient.
SRC Spinemate - only used or reproduced with written permission from SResourceC@aol.com