Backache: Predicament at Home, Nemesis at Work

I am going to direct my comments to those of us of working age who have or have had or will have a backache or arm pain: That is all of us. Almost all of us, all the time, are otherwise well. But our predicament of back or arm pain is always more challenging than it need be mainly because we carry the baggage of misinformation. Backache and arm pain are intermittent and remittent predicaments of life. It is abnormal to live 1 year without an episode of backache or 3 years without an episode of arm pain. Before you race to the medicine chest, the purveyor of care, or even the company nurse, reflect. The reason you owe yourself time to reflect is that you have nothing to lose in doing so and much to gain. I am not belittling the discomfort—it can be damnable. But, if you can cope, you are likely to be rewarded with regression in your symptoms, and reasonably soon too. Furthermore, this is your best option. I appreciate that attempting to rely on one’s personal resources in contending with a backache or arm pain is a trying exercise in any circumstance. In contemporary America such coping has become nearly impossible. There are three daunting obstacles:

Coping has been rendered counterintuitive.
Coping must contend with the illness of work incapacity that confounds many regional musculoskeletal disorders.
Effective coping, the most diabolic challenge of all, involves distinguishing whether the experience is less tolerable because it is confounded by any of a myriad of life stresses at home and on the job.

Similar considerations pertain to all the regional musculoskeletal disorders. In this chapter we will take backache and arm pain as the object lessons. However, the chapter should be viewed as introductory in the sense that we will return to these three obstacles in great detail elsewhere in this section and in later sections of the monograph.

BACKACHE AND COMMON SENSE

More than 70 years have passed since the formulation of the “ruptured disc” hypothesis dramatically altered common sense about acute backache. For 70 years we have been able to “injure” our backs in the absence of trauma. For 70 years we have been able to conceptualize the pathophysiology of the pain. For 70 years we have stood, bent and bowed, before the incisiveness of the surgeon. For 70 years
Workers’ Compensation Insurance programs have certified and indemnified all this reasoning. For 70 years we have embraced our common sense with a tenacity that belies a voluminous empiric and progressively scientific body of information to the contrary. It is time for a new common sense. In fact, that is long overdue.

TABLE 2.1. QUALITIES OF A REGIONAL BACKACHE

There has been no traumatic precipitant involving external force.
If it were not for the pain in the low back, you would feel well.
There are postures, usually recumbent or standing fully erect, that offer some relief.
Movement of the low back, particularly flexion, exacerbates the symptoms.
Rolling over in bed may be painful, but you are not awoken by aching and throbbing pain.
The pain does not cause you to move, pace, fidget, or writhe.
There is no change in your bowel or bladder function that cannot be readily ascribed to overcoming the biomechanical challenges inherent in using the American toilet.

Regional back pain¹ denotes the low back pain experienced by individuals of working age whose daily lives present biomechanical demands that are not extraordinary, who have experienced no violent precipitant, who are otherwise well, and who have no important neurologic signs even if their pain radiates (Table 2.1). The following maxims pertain to regional back pain, maxims about which we can restructure the common sense of today and from which we can go on to generate the new information needed to formulate the common sense of tomorrow.

Maxims

Regional back pain
- is a remittent, intermittent, escalating predicament of life;
- is indeterminate in cause but predictable and unassailable in course;
- is biomechanically disadvantageous, thereby challenging function; and
- is less likely to arise out of employment than the common cold.
Regional back pain
- cannot be prevented.
Regional back pain
- that compromises one’s work performance calls for empathy;
- that compromises workers’ performance is more likely a reproach to company management than a challenge to ergonomics; and
- that is indemnified by Workers’ Compensation Insurance is confounded and more morbid.

These maxims were set forth in the Second Edition of this book and remain fully consistent with the state of the art and the state of the science to this day. They are to be held up against all our preconceived notions. They can be flaunted
in defiance of those who construct lifting guidelines, those who promulgate lifting regulations, and those who indemnify back “injuries.” They vanquish the sophisms of those who rush to image, cut, poke, and prod. They are a new common sense that promulgates social progressiveness; the American worker deserves and has earned a workplace that is secure and comfortable when she or he is well and accommodating when she or he is ill, even ill with regional back pain.

The following is the basis for these maxims.

The Experience of Regional Back Pain

Back pain afflicts the adolescent,²,³ the elderly,⁴,⁵ and all in between,⁶,⁷ and does so frequently.⁸ Both the incidence and prevalence of back pain varies from study to study depending on the fashion in which the symptom is elicited. If people are asked to keep a diary of events, day by day, the incidence is ubiquitous. If people are asked to recall events, memory and the format of the question (e.g., Do you recall back pain lasting _____ days in the past ______ weeks?) become crucial variables.⁹ Each year as many as 50% of us experience a memorable episode of back pain. As many as 10% to 20% of us recall the challenge as daunting regardless of age, nationality, gender, or station in life. Some of us live a nightmare. Telephone interviews with more than 4000 randomly selected adults in North Carolina unearthed the disturbing fact that 3.9% experienced back pain for more than 3 months, or experienced more than 25 episodes, during the course of a single year.¹⁰ Fortunately, for most of us the episodes of backache are rapidly remittent, usually within a few weeks, albeit highly intermittent.¹¹

Any time you experience regional back pain, you have a predicament. In addition to the pain, mobility and function become challenging. Because leaning forward impressively increases the force vector across the lumbar spine, even writing at a desk can exacerbate the pain. Lifting or assuming awkward postures can be prohibitive. A recumbent posture helps, but you have to be fully recumbent despite boredom and uselessness. The predicament of regional back pain forces us to make choices: Carry on somehow, seek the ministrations of a professional of some ilk, or, if work performance is compromised, seek recourse in the context of workplace health and safety.

Detailed understanding of this choosing, of processing the predicament of regional back pain, is difficult to come by. Interview surveys are plagued by biases in recall.⁹ Asking people to keep a diary, as was done in the “Health in Detroit” study,⁸ may be the closest we can come. Musculoskeletal discomfort, mostly regional back pain, afflicted 51% for an average of 8 days in a 6-week period. Most ingested over-the-counter (OTC) analgesics. Few took time off from work; only 0.3% saw a doctor. This survey is a glimpse of processing in one small universe, at one point in time. It need not generalize. After all, even the prevalence of memorable back pain is different across cultures,¹² across sociologic strata,¹³ and over time.¹⁴

These differences and trends reflect the fact that processing is easily perturbed. Everyone has advice to offer, mostly unsolicited. Advertising trumpets mattresses, automobile seats, and more. Practitioners offer to push, pull, prod, or soak, to exercise, educate, or gird your loins. All this unsubstantiated zeal¹⁵,¹⁶ enjoys a self-fulfilling
prophecy that overwhelms caveat emptor. Most episodes of regional back pain regress spontaneously within a fortnight, although recurrences and waxing and waning are frequent experiences.¹⁷ Who can purchase assistance, then experience improvement, and not assume palliation? Any doubt is assuaged by some theory that explains the benefits and justifies the costs.

The pharmaceutical industry was born in this marketplace and continues to thrive there (Chapter 4). More and more analgesic/anti-inflammatory drugs are heralded for OTC use. A fortune is spent on direct-to-consumer advertising of prescription analgesics. Why? So that when we experience our next episode of back pain or other regional musculoskeletal illness, an OTC remedy will seem a clever first option. A generation ago most people with the predicament of back pain sought relief in patent OTC remedies (containing salicylates or phenacetin). The marketplace today is driving toward saturation. To whose benefit? At what risk?

Choosing to Seek Professional Care Outside the Context of the Workplace

Rarely is the intensity of regional musculoskeletal pain or even the compromise in physical function sufficient to drive one to seek the help of others. Psychosocial confounders contribute and often predominate. The first clues to this dialectic emerged from studies of back pain in the workplace 30 years ago¹⁸ and of knee pain in the elderly more recently.¹⁹ The regional musculoskeletal pain is rendered far less tolerable when the rest of our life is not in order. People cease persisting as people and seek out help because they can no longer cope on their own. Such people frequent medical offices with the chief complaint, “My back hurts.” That complaint should be interpreted to mean “My back hurts, but the reason I’m here is that I can’t cope on my own any longer.” Otherwise, the treating physician might try to squelch regional back pain with analgesia and the proscription of function with the result that the patient’s satisfaction with care, understanding of the illness, and function will suffer further.²⁰ A quest by the treating physician to define the anatomic cause of the pain is, nearly always, a diabolic fool’s errand.²¹ There is NO scientifically validated indication for violating the integrity of the lumbosacral spine of such a patient²²; assertions to the contrary represent monumental hubris. The only patient-physician contract that can be successfully enjoined relates to coping.²³

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