Input (Bio), Output (Psycho), and Upstream (Social) Factors in Disabling Back Pain

Craig Liebenson

Joshua Wideman

Tim Latham

James E. Eubanks

LEARNING OBJECTIVES

After reading this chapter, you should be able to understand:

Why upstream factors may be the most influential to address from a behavioral perspective.
How sustainable lifestyle changes upstream can be facilitated with a community planning or public health political agenda.
The clinical relevance of the concepts of spine stability and instability.
The basis for dynamic systems theory (DST) as it applies to spine care.
The tensegrity model of spine stability.
How central sensitization can explain how an individual can perceive pain in the absence of tissue damage or injury.
The relationship between pain and motor control.
The role of protective responses such as agonist and antagonist muscle coactivation in stabilizing the spine.
The role of movement variability and motor control in injury risk.

“Yet all experience is an arch where through gleams that untraveled world whose margin fades, Forever and forever when I move.

–LORD ALFRED TENNYSON

Introduction

Traditionally, rehabilitation of musculoskeletal disorders was approached through a biomedical lens. This view is often described as looking for “issues in the tissues” where the identification and treatment of structural pathology are the primary focus. Within this model, modern imaging technologies have been heavily utilized to guide patient care in an attempt to create efficiency, objectivity, and reduce pain or injury to its constituent parts.¹ Clinicians and patients alike have been mesmerized by modern technology’s ability to visualize the anatomic substrate of the patient’s pain. However, just as a picture of a phone does not tell you if it is ringing, the ability of imaging modalities to inform us about the spine’s function, the patient’s subjective experience, and their pain tolerance is limited. The biomedical model and the overutilization of imaging procedures has created a disconnect between the patient and his or her symptoms or experience. In fact, it is likely that imaging—when not indicated—can actually be harmful by leading to unnecessary worry (i.e., overdiagnosis) and procedures.

A central goal of musculoskeletal rehabilitation is to restore function, prevent disability, and maintain a sustainable relationship with activity. The means to that end involves overcoming any barriers to patient reactivation that may be present. This includes avoiding overly aggressive or passive management, from both a diagnostic and therapeutic standpoint, that erects new barriers! Musculoskeletal medicine should promote an active, patient-centered, and self-care-oriented approach.

Psychosocial factors have been recognized as significant contributors to a patient’s recovery. This has revolutionized spine care as the biopsychosocial (BPS) model (see Chapter 3).¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸ The BPS model serves as an integrated approach to the management of painful and potentially disabling musculoskeletal conditions. This model considers the interaction of biologic (structural, biomechanical, biochemical, etc.), psychological (behaviors, mood, etc.), and social (socioeconomic, cultural, community, etc.) factors (see Table 1.1). The “bio” takes the form of a more linear input-driven way of thinking because it is easier to study. In reality, biology is a nonlinear process. The “psycho” is an above down descending modulation with various neurophysiologic protective (output) responses; the “social” involves upstream factors influencing the environment within which one’s capability to alter lifestyle in a positive or negative way is optimally “nudged.”

Table 1.1 The Biopsychosocial Model—An Overview

BIO—primarily a linear input approach focused on pathology, the tissue, or biomechanics
PSYCHO—above down descending modulation of protective (output) responses
SOCIAL—upstream factors involving the environment (social, occupational, political, community, economic) in ways that have potential to nudge an individual or group’s lifestyle behavior change

Low back pain (LBP) is very common (see Chapter 4) and the number one cause of disability globally.⁹ The recent Lancet Low Back Pain Series Working Group papers called for implementation of the guidelines acknowledged and disseminated in literally dozens of reports over the last three decades!³^,⁵^,⁶ In addition, they recommended “coordinated political action from international and national policy makers, including World Health Organization (WHO) and research funding agencies.”³^,⁵^,⁶ According to Ostelo, in a recent Spine editorial “Another (grim) message reflects on the management of LBP, more specifically, on the massive gap that exists between evidence-based medicine (EBM) and the management delivered in every day care.”⁹

The great challenge of disabling back pain is that “for real change more than simply informing relevant stakeholders is needed.”⁹ It is now necessary that we squarely put the bull’s eye for addressing the political-economic milieu upon which the low back disability epidemic has thrived on an upstream approach. As Ostelo states, “In an world in which complex organizational structures and vested interests are dominant, the challenge now is to transform this ‘call for action’ into ‘real change.’”⁹

The complexity of interactive dynamics surrounding LBP is highlighted by the fact “that LBP is a complex condition with multiple contributors to both the pain and associated disability, including psychological factors, social factors, biophysical factors, comorbidities, and pain-processing mechanisms.”⁹ Most stunningly for the medical-industrial complex surrounding overdiagnosis, the medical cascade, and interventionism with low-value approaches (e.g., inappropriate spinal fusions) is that “however, intuitively obvious the multifactorial nature may seem, the reality is that the evidence for most ‘well known’ risk factors is not overly convincing.”⁹ Ostelo’s unmasking of typical nonevidence-based practice is summed up thus: “Unfortunately, a substantial number of the strategies currently applied, promoted, and reimbursed in daily
practice are more aggressive treatments of dubious benefit associated with potential harms.”⁹

With this as a backdrop, the remainder of this chapter and hopefully the entirety of “Rehabilitation of the Spine: A Patient-Centered Approach” will touch on a multisystem dynamic approach to the BPS paradigm. The hope is to bridge the gap between the “tissue” and “brain” or biomechanics and pain science schools of thought. A modern “systems” view of spine care can’t merely focus on biomechanics, tissue injury, or nociceptive inputs (i.e., biologic). Nor can it exclusively emphasize one’s interpretation of the harmfulness (i.e., psychological) of an “injury,” postural or movement fault, or structural diagnosis. A systems view can’t ignore the third pillar of the BPS approach that addresses social and cultural factors that influence lifestyle choices. These are typically upstream and related to political and economic vested interests. It is this third underappreciated pillar with which we will start.

The Social and Upstream Dimension: BPS

If we are to make a positive impact in managing disabling back pain, we must not underestimate upstream social factors. Upstream factors are social determinants of health that are present long before a person seeks a health care provider (HCP).¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸ The upstream model of health care could also be seen as the “anticipatory model to health care.”¹⁸ This model looks at ways to influence behaviors that address preventable, lifestyle-related disease.

Examples of upstream approaches include:

Lay-led patient education classes
Group fitness classes, walks, and hikes
Community planning measures to create pedestrian- and bike-friendly “no car” zones
Insurance companies withholding payment for unnecessary imaging, injections, or surgery
Insurance companies offering greater access to rehabilitation services
E-devices, apps, etc., aimed at providing behavioral nudges

The Spine Disability Epidemic: The Modern Inactivity Crisis

Life span is greater than health span, and the gap is growing wider. As our population ages, even though we are living longer we are not necessarily living better. In fact, as life span increases, the years lived with disability (YLD) is actually increasing. With an aging population, lifestyle-related factors become a more significant determinant of health. Smoking, drinking, and overeating are hallmark lifestyle behaviors that have been shown to be associated with 10 to 14 years of YLD (see Table 1.2).¹⁹

Table 1.2 Lifestyle Modifications Can Enhance Life Span 12 to 14 Years

Adherence to five low-risk lifestyle-related factors (never smoking, a healthy weight, regular physical activity, a healthy diet, and moderate alcohol consumption) could prolong life expectancy at age 50 years by 14.0 and 12.2 years for female and male US adults compared with individuals who adopted zero low-risk lifestyle factors.

According to the Centers for Disease Control and Prevention, physical inactivity in the United States is at 77%.²⁰ Physical inactivity is one of the most important lifestyle factors affecting health.²¹ The role of physical activity (PA) is underappreciated despite evidence of its protective effects (see Fig. 1.1).²¹ The costs associated with physical inactivity affect people in both rich and poor nations.²¹ Alarmingly, 23% of adults and 81% of adolescents (aged 11-17 years) around the world don’t meet the World Health Organization (WHO) global recommendations on PA for health.²²

Physical inactivity is considered the fourth leading cause of global mortality.²³ It is a modifiable risk factor that affects health across the life span (see Chapter 4 for a more comprehensive review of the relationship of inactivity, noncommunicable diseases [NCDs] and disability).²⁴

HCPs (e.g., medical physicians, chiropractors, nurses, and physiotherapists) can evaluate patients’ PA behavior using the 5A framework (assess, advise, agree, assist, arrange)²⁵:

Assess patients’ PA level, physical abilities, readiness to change, and beliefs and knowledge;
Advise on health risks, the benefit of change, and appropriate dose of PA;
Agree upon an action plan with achievable goals;
Assist patien.ts in identifying and addressing barriers;
Arrange follow-up with reminders to monitor progress.

Figure 1.1 The influence of physical inactivity. Adapted from Booth FW, Roberts CK, Thyfault JP, Ruegsegger GN, Toedebusch RG. Role of inactivity in chronic diseases: evolutionary insight and pathophysiological mechanisms. Physiol Rev. 2017;97(4):1351-1402.

Assessing the amount of moderate PA per week could quickly become a standard of care in clinical practice by asking two simple questions²⁶:

“On average, how many days per week do you engage in moderate or greater intensity PA (like a brisk walk)?”
“On average, how many minutes do you engage in this PA in those days?”

To achieve the minimal WHO recommendations for cardiorespiratory endurance exercise, the product of the two responses should be ≥150 minutes per week (≥75 minutes per week for vigorous PA only).²⁷ If the patient does not meet these recommendations, he/she should be advised to engage adequately in PA according to his/her capability. Specific recommendations according to types of chronic disease have been published by Pedersen and Saltin.²⁸

How Did We Get Here? LBP is ubiquitous; symptoms often persist and are likely to return (see Chapter 4).³^,⁵^,⁶^,²⁹ This persistence often leads to fear and uncertainty that is not adequately addressed in most guidelines (see Chapter 2).³⁰^,³¹ Because patients are told not to worry when symptoms inevitably continue or recur, their concern only grows.

Avoidance behavior, overprotection, and hypervigilance are hallmarks of the descent from acute to chronic pain (see Chapter 12). Flores et al have shown that “prospective intolerance of uncertainty” is a factor in this progression into vulnerability.³²

Uncertainty is common but all too often doctors overpromise and underdeliver, thus leading to patient dissatisfaction. Simpkin and Schwartzstein state, “Although physicians are rationally aware when uncertainty exists, the culture of medicine evinces a deep-rooted unwillingness to acknowledge and
embrace it.”³³ “Orthopaedic surgeons are known not to treat themselves as they would treat their patients and suffer from an overconfidence bias.”³⁴ William Osler more than 100 years ago said, “The greater the ignorance, the greater the dogmatism.”³⁵ According to Ring, “As a science-based profession, orthopaedic surgeons should be encouraged and trained to value and recognize uncertainty. We should build checklists and systems to catch errors before they cause harm; expect our impressions (and those of the patient) to sometimes be contradicted by objective, reproducible evidence; and work as teams on difficult diagnostic and treatment dilemmas.”³⁶

Flores et al state, “The unintended consequence—an obsession with finding the right answer, at the risk of oversimplifying the richly iterative and evolutionary nature of clinical reasoning—is the very antithesis of humanistic, individualized patient-centered care.”³² The challenges physicians face in accepting uncertainty are associated with suboptimal patient care, excessive ordering of tests that carry risks of overtreatment for false-positive results, and iatrogenic consequences because of over-interventionist care with unnecessary downside risk.¹³^,³⁷ In a nutshell, it comes down to “making people patients unnecessarily, by identifying problems that were never going to cause harm or by medicalizing ordinary life experiences through expanded definitions of diseases.”¹³

One recent summary of the literature on rotator cuff (RC) problems echoes the issues in spine care.³⁸

The prevalence of RC tears increases with age.
Asymptomatic RC tears are common, especially in people over 50 years old.
Asymptomatic RC tears are common.
Approximately 40% of RC’s retear or fail to heal following surgery, with no significant difference in outcome (functional or symptomatic) than those patients who are said to be healed.

The authors conclude: “It therefore seems timely to recognize the enigma of the RC tear and make the case for uncertainty with regard to clinical decision-making.”³⁸

Cultivating a tolerance of uncertainty requires a revolutionary change in medicine’s cultural attitude.³² Medical education will need to be modified to emphasize the process of clinical reasoning, the presence of optionality rather than there being a single “right” answer, and an appreciation of the patients’ values.¹³^,³² According to Flores, “Educators can start by asking questions that focus on ‘how’ and ‘why,’ not ‘what’—stimulating discussion that embraces the gray-scale aspects of human health and illness, aspects that cannot be neatly categorized, and encouraging students’ curiosity to explore the capacity to sit comfortably with uncertainty, acknowledging that certainty is not always the end goal.”³² The scientific method can reestablish itself in health care by the emphasis on generating hypothesis rather than firm diagnosis. A key is teaching physicians how to communicate about scientific uncertainty, which is a prerequisite for shared decision making.³²

The typical “label” given is nonspecific LBP, which leads to a “one-size-fits-all” approach. The mistake is assuming patients represent a homogeneous population (see Figs. 4.1 and 4.2 in Chapter 4).³¹ The misleading label “nonspecific” leads to “medicalization” of the problem by physicians trained in the bio approach of the BPS model seeking the “cause” of LBP.³^,⁵^,⁶^,¹⁴^,³¹ According to Rampersaud et al, “Medical training and societal expectations dictate that we must establish a cause for the pain and base our therapy on a recognized pathology. This makes sense for diseases for which there are reliable means of diagnosis and an associated remedy. But, most patients complaining of LBP experience symptoms from a minor mechanical disturbance, not a disease. The severity of the pain, which can be extreme, does not reflect the seriousness of the underlying problem.”³¹ LBP can be viewed as an illness like a cold or flu rather than a disease. In this context, seeking an exact diagnosis is not always required so long as sinister “Red Flags” are ruled out and the reasoning is explained as to why a reassuring positive prognosis is clear.

Political and Economic Influences Although focus on overdiagnosis and “too much medicine” is common today, the key question is how funding of such frequently inappropriate health care services has become so entrenched in our modern health care experience.¹³^,³⁹^,⁴⁰ The influence of these upstream factors in promoting unhealthy beliefs and behaviors in patients cannot be overestimated.¹³^,³⁹^,⁴⁰ In the future, “we need to ensure that new disease definitions are based on evidence not financial interests.”¹³^,³⁹ An article about knee arthroscopy states, “how we organize, finance, and deliver healthcare may drive rates of healthcare intervention more than need or benefit.”⁴¹ Upstream systems do patients a disservice if they ignore evidence-based research when determining funding choices.

According to Moseley, “Back pain is not a simple problem. There are many forces at play that propagate its widespread mismanagement. The massive elephant in the room—that entire professions appear to depend on the problem remaining unsolved—will be hard to tackle.”⁴² This is not merely a clinical problem but a political one.⁴³

Jevne states, “Many systems provide only a marginal reimbursement for exercise therapy as a conservative approach in musculoskeletal (MSK) care. Conversely, when patients are referred for surgery, both the surgical procedure and the postoperative course are typically fully funded. When patients are financially incentivized to proceed with invasive interventions, one could easily suggest that the system is ‘priming’ patients toward these treatments.”⁴⁰ Modern pain education is another example of an evidence-based approach that is currently not reimbursable.⁴²

Why is it that preventive interventions that have evidence of efficacy are ignored or adopted slowly? According to Pryor and Vlopp, “The first issue is that, historically, far more resources have been devoted to treating disease than to preventing it; in 2015, only 3% of health care dollars were spent on preventive services.”⁴⁴ As a result, there is a systemic overprovision of treatments and underprovision of preventive services, which is exacerbated by high turnover in many health insurance markets.⁴⁴ They state that most insurance contracts tend to be only 1 year long, so insurers lack an incentive to spend money on prevention when the insured members may be covered by a different insurance company by the time they develop a preventable disease. In other words, they don’t have “skin in the game.”¹⁵^,⁴⁵

A possible solution is proposed by Jevne in Table 1.3.

One example of the “fee-for-service” reimbursement side of the disability problem is the opiate crisis. According to Goertz and George, “Low back pain is one of the most common reasons patients seek medical care and is highly correlated with opioid use … (that has) contributed to a major public health crisis resulting from opioid overuse and misuse.”⁴⁶ A challenge for upstream solutions to this crisis is if insurance companies will alter current policies in order to integrate evidence-based guidelines for nonpharmacologic treatment of painful disability into existing reimbursement systems.³^,⁵^,⁶^,⁴⁷

Heyward et al⁴⁸ conducted a cross-sectional review of 45 insurance company web sites and 20 qualitative interviews with 43 health plan executives about coverage policies on nonpharmacologic care and reported that significant barriers to patient access were identified for all covered nonpharmacologic therapies.

It is recommended that insurance companies need to accept evidence-based findings and avoid the stigma that nonpharmacologic treatments are inferior to conventional medical approaches.⁴⁶ According to Goertz and George, “restricting access to opioids without addressing the underlying problem of chronic care management for low back pain is unlikely to positively affect the opioid crisis. Well-conceived guidelines that encourage the use of evidence-based, non-pharmacological treatment options exist and must be enabled by changes in public health policies that better guide care delivery and reimbursement. Health plans are uniquely positioned to bring about the sweeping changes needed to offer diverse pain management options for individuals with chronic pain.”

The bottom line is that in the majority of cases when compared with commonly used pharmaceutical options nonpharmacologic treatments are of³^,⁵^,⁶^,⁴⁹

greater benefit;
lower risk;
and lower cost.

According to Koh, a lack of health literacy is a major public health problem, with only 12% of US adults having a “proficient state of health literacy.”⁵⁰ Patients are routinely misinformed about benefits and
harms in medicine,⁵¹ this is well recognized in musculoskeletal conditions in general pain and LBP specifically.⁵²^,⁵³ According to Jevne, “In a modern healthcare system largely based on cultural trust, it is plausible that reimbursements can create illusions of safety and effectiveness.”⁴⁰

Table 1.3 Rethink Funding to Change Behavior⁴⁰

Ensure evidence-based reimbursement structure of conservative care
Even the playing field between practitioner and patient
Change widespread misconceptions

How Did We Become so Inactive? A key question is what are the drivers of our current inactivity crisis? From a functional perspective, the human tendency to avoid intentional physical exertion served an energy conservation purpose.⁵⁴ This maintained energy reserves and was necessary for our survival among our evolutionary ancestors.⁵⁴ Lee et al state, “The fact that these tendencies—which together represent the exercise-affect-adherence pathway—are innate does not mean that they are unchangeable …. We share with all animal species the genetically engrained tendency to be efficient when it comes to expending energy.”⁵⁴

Modern life has promoted inactivity as a result of cars, buses, trains, etc. (see Fig. 1.2). However, we can create conditions under which physical exertion is more purposeful. Community planning that creates no-car zones is an example of an upstream solution that promotes walking or biking. Political will via taxing cars entering a city or, as in Beijing, banning cars with odd or even license plates every other day has an influence on both physical health and the environment.

Figure 1.2 Make physical activity a part of daily life during all stages of life. Reprinted with permission from Gates A, Murray A. Infographic: make physical activity a part of daily life at all stages in life: an infographic. Br J Sports Med. 2016;51(10):825-826. Reprinted with permission from World Health Organization. Infographic: Make physical activity a part of daily life during all stages of life. http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/data-and-statistics/infographic-make-physical-activity-a-part-of-daily-life-during-all-stages-of-life

As medicine evolved, “the clinical and public health claims of biomedical reductionism were grossly
overstated and that most of these mortality decreases reflected the roles of nutrition and economic development.”⁵⁵ According to McKeown, most infectious diseases that ravaged human populations came under control in the late 19th century not as a result of biomedical advances but as a result of humanitarian reforms aimed at reducing overcrowdedness, stagnant pools of water, and better waste management.⁵⁶ The “magic bullet” ideology borne out of medical reductionism is as much myth as reality.⁵⁷^,⁵⁸^,⁵⁹

Behavior is influenced by a complex web of interacting systems. Greene and Loscalzo state, “It is thus important to re-conceive biologic and patho-biologic phenomena in terms of complex networks of interacting genes or gene products and layers of environmental modulators. Network science has roots in sociology, which explores the behavior of social networks, and in the mathematical field of graph theory.”⁵⁵^,⁶⁰^,⁶¹

In DST, the concept of constraints or boundary conditions is used to describe nonlinear interactions of different variables or constraints in an ecologic system.⁶²^,⁶³ Newell’s constraints model⁶⁴ distinguishing three categories of constraints or risk factors (organismic or personal, environmental, and task-related) has been successfully applied to physical therapy and rehabilitation,⁶⁵^,⁶⁶^,⁶⁷ “Personal, task and environmental risk factors (constraints) interact dynamically and non-linearly at different levels and timescales to increase the susceptibility” to painful conditions.⁶³

Epigenetics, social genomics, biobehavioral medicine, and psychoimmunology all highlight the interconnectedness of individuals and their environment.⁶⁸ Lifestyle choices are influenced by a host of upstream factors listed in Table 1.4.

Viewed through the lenses of evolution, history of medical science, politics, and interactive dynamics, we can begin to appreciate that “Human health should therefore be understood as a complex system … rather than looking at individual agents.”⁶⁸

The different components are shown in Table 1.5. The human body is nested to broader social influences such as family, school, and the workplace (see Table 1.6).⁶⁸

Complexity science is an attempt to understand the dynamics of the interactions between numerous variables. The causal loop diagram is one such example of how daunting this process is (see Table 1.7).⁶⁸^,⁶⁹^,⁷⁰^,⁷¹ The biologic, psychological, and social influences on lifestyle and health are enormous.

Evidence-based health care (EBHC) has developed over the past few decades as an attempt to help HCPs keep pace with the daunting volume of scientific literature (see Chapter 2). Further to this goal has been the work of experts in meta-analyses and groups like the Cochrane Collaboration who summarize the literature for practitioners in the trenches. “One of the consequences is that there is much debate on what constitutes evidence, but the more important question is what types of information, facts, reasons, and values are useful for clinical decision making.”⁷²

Table 1.4 Upstream Factors

Available information
Upbringing
Peer group behavior
Perception
Available food stores
Media
Stress
Social norms

From Van Wietmarschen HA, Wortelboer HM, van der Greef J. Grip on health: a complex systems approach to transform health care. J Eval Clin Pract. 2016;24(1):1-9.

Table 1.5 Complexity Science Considers These Components

Global dynamics of the system as a whole
The self-organization toward certain states
The resilience of these states
The critical transitions between states

From Van Wietmarschen HA, Wortelboer HM, van der Greef J. Grip on health: a complex systems approach to transform health care. J Eval Clin Pract. 2016;24(1):1-9.

Table 1.6 Broad Social Influences Nested Together That Affect Health

Individual

Family

Workplace

Community

From Van Wietmarschen HA, Wortelboer HM, van der Greef J. Grip on health: a complex systems approach to transform health care. J Eval Clin Pract. 2016;24(1):1-9.

Table 1.7 Causal Loop Influences of Multisystem Interactions

Energy

Inflammation

Glucose metabolism

Physical

Cognitive

Gastrointestinal

Psychophysiologic stress

Coping

Motivational

The gold standard for EBHC is the randomized controlled trial (RCT). However, statistical power requires large patient pools, which as a consequence include a heterogeneous pool (see Figs. 4.1 and 4.2 in Chapter 4). Knowledge gained is more a lowest common denominator of what to avoid (i.e., prescription of bed rest) rather than what to do. A precision N = 1 approach recognizes that care must be individualized. Thus, the generalizability of the results of such trials is very limited.⁶⁸^,⁷³

Another important concept often ignored in RCTs is allocation bias (see Fig. 1.3). This is defined as a “Systematic difference in how participants are assigned to treatment and comparison groups in a clinical trial.”⁷⁴ It is estimated that over 80% of trials may suffer from this and it can lead to overestimation of effects by as much as 40%.⁷³

Repositioning evidence is crucial if we are to transition toward more patient empowerment and personalized approaches. “Specific techniques based on concepts from complexity science provide opportunities to analyze this N = 1 type of data.”⁵¹ An anticipatory mindset is needed to funnel patients to the most efficient approach. The “right treatment, at the right time, for the right person” is our goal. Some need an upstream, community planning public health measure like better access to bike paths. Others in lower socioeconomic areas need access to advanced imaging and appropriate interventions,³^,⁵^,⁶ whereas those in higher socioeconomic regions may benefit from point-of-contact musculoskeletal specialists with training in how to educate patients about the value of self-care and low evidence base (and possible downside risk) of passive modalities and experimental interventions (e.g., stem cells and platelet-rich plasma).³^,⁵^,⁶

Figure 1.3 Allocation bias. Reprinted with permission from Spencer EA, Heneghan C, Nunan D; Catalogue of Bias Collaboration. Allocation bias. In: Catalogue of Bias. 2017. https://catalogofbias.org/biases/allocation-bias/

In a recent editorial about the Lancet series on LBP the authors warn, “We are slightly concerned that further attempts to identify pain sources will be further reductionist steps to solve a complex issue.”⁷⁵ They emphasize that “the series itself discusses how tissue ‘input’ can be modified according to the responsiveness of the central nervous system and that ‘the advances with the greatest potential reduce focus on spinal abnormalities’.”⁷⁵ A major issue will be how to change the narrative about back pain so as to shift the focus away from lower-value strategies toward higher-value ones (see Chapter 13).

Social Determinants of Behavior

Developing a Mindset About Social Factors Although the bio and psycho components have gotten the most attention over the last 30 years, it is the social that may ultimately have the greatest impact from an upstream perspective. Heightened awareness of the role of all three pillars is key: “the social component of the biopsychosocial model is the weakest component … and is scarcely mentioned in practice guidelines, as the latter mainly target nociceptive sources of pain and disability. Yet, like personal factors, environmental factors may have a significant influence on outcomes.”⁷⁶^,⁷⁷

The history-taking with a patient is vitally important for compassionate communication. It is a one-time opportunity to listen to reflect upon a person’s history and situation. “When a patient presents with disability, clinicians need to explore the influence of contextual elements related to the patient’s occupation (work) and social context (i.e., family) on the patient’s painful symptoms and disability.”⁷⁶^,⁷⁸

Motivation or “readiness to change” is a state that can be changed, rather than a fixed personality trait. Clinicians can apply motivational principles to improve patient adherence to self-management approaches (see Table 1.8).⁷⁹ Motivational interviewing (MI) is an example of a method to facilitate behavioral change by focusing on three elements: (a) importance, (b) confidence, and (c) readiness.⁸⁰ MI is an evidence-based way to work with patients that focuses on “developing a partnership, eliciting and accepting the patient’s perspective, values and autonomy, and meeting the patient with empathy and compassion” (see Table 1.8).⁸¹^,⁸²^,⁸³

Social cognitive theory highlights that individual factors such as attitude, knowledge, and motivation are key determinants of lifestyle behaviors and should be targeted via educational strategies.⁸⁴^,⁸⁵^,⁸⁶^,⁸⁷ Unfortunately, “educational interventions targeting these individual-level level factors often lack sufficient effects in changing behaviours and health, especially on the longer term, and particularly in lower SES
groups.”⁸⁸^,⁸⁹ It is plausible that this may be due to the inadequate consideration of the social, physical, and economic context in which inactivity flourishes.⁸⁸

Table 1.8 Hallmarks of Motivational Interviewing—OARS

O—Ask open questions. Seek to understand the patient’s goals, values, and priorities. Identify barriers and facilitators. Seek to build trust through relatedness.

A—Use affirmations or positive statements to demonstrate interest in patient’s views. Avoid trying to convince or persuade the person. Collaboration vs. confrontation.

R—Commitment to reflective and empathetic listening to hear patient’s story with minimal interruptions.

S—Summarize the patients’ story so they know that you’ve heard them. Empower the patient with achievable goals that challenge them but have “wiggle” room. Make a plan collaboratively.

Finding a social context for a person’s activity-limiting disability beyond merely focusing on their symptoms, biomechanics, emotional stress, cognitive understanding, or structural pathology is important. As Rabey et al stated, “a flexible, biopsychosocial classification system may allow profiling across multiple relevant dimensions, to facilitate targeted care based on the dominant factors present in individual profiles” (see Fig. 1.4) (see Chapter 7).⁹⁰

How is it that HCP knowledge gains about disability prevention and PA promotion have not translated into improved outcomes for patients? According to Gates et al, “We suggest that one convincing explanation may be that while these national activity plans set out a proposal for multi-sector collaborative approaches, they fall short because they fail to address how professionals and stakeholders develop and deepen an understanding of PA promotion.”⁹¹ Placing all the emphasis on practitioners and patients is a decisive error: “In practice, individual stakeholders continue to work, learn and influence in relative silos. We argue here that a potential solution to this problem is to develop a true community of practice.”⁹¹^,⁹²^,⁹³

Communities of practice are a promising approach that can help achieve the WHO Member States’ pledge to reduce physical inactivity by 10% by 2025 (see Table 1.9).⁹¹ They are a necessary accessory to EBHC in order to make sustainable changes.⁹⁴ In Figure 1.5 the partners in this process are listed.

All the above players will need to become better aligned “to the vision of reducing physical inactivity.”¹⁶^,⁹¹ Finally, according to Gates et al, “Building a community of practice will break down the silos in thought and action by generating a social infrastructure that engenders bottom-up, rather than top-down, approaches.”⁹¹

In light of the global pandemic of inactivity, sedentarism persists despite many initiatives aimed at tackling the problem.⁹⁵ Multiple stakeholders are attempting to promote PA without sufficient coordination or impact.⁶² Currently, there is a call to action to bring relevant stakeholders (e.g., government, civil society, private sector, nongovernmental organizations, and sport bodies) together into synergistic partnerships.⁶²^,⁹⁶^,⁹⁷

Figure 1.4 Multidimensional pain drivers. Reprinted with permission from Rabey M, Beales D, Slater H, O’Sullivan P. Multidimensional pain profiles in four cases of chronic non-specific axial low back pain: an examination of the limitations of contemporary classification systems. Man Ther. 2015;20(1):138-147.

Strategies to promote PA should build on past experiences from other large-scale health promotion initiatives including tobacco control or immunization programs.⁹⁸^,⁹⁹ Bull and Bauman suggest that implementation within existing health service structures, community involvement, research initiatives,
and public communication would be some methods to serve the needs of large-scale health promotion.⁹⁸ Popular media can also be targeted to promote PA.¹⁰⁰ Working in isolation won’t be sufficient to create a change in PA levels.⁹⁸

Table 1.9 The Community of Practice Team Includes

Sport and exercise doctors and clinicians
Rehabilitation specialists (Physiatrists, Physical Therapists, Chiropractors, Athletic Trainers)
Kinesiologists
Exercise physiologists
Sport and exercise scientists
Public health specialists
Health care and fitness professionals
Community outreach workers
Charity workers

From Gates AB, Kerry R, Moffatt F, et al. Editorial: Movement for movement: exercise as everybody’s business? Br J Sports Med. 2017;51(10):767-768.

Figure 1.5 Community of practice. Adapted from Gates AB, Kerry R, Moffatt F, et al. Movement for movement: exercise as everybodys business? Br J Sports Med. 2016;51(10): 767-768; with permission from BMJ Publishing Group Ltd.

The WHO states that to achieve the PA and the Sustainable Development Goals (SDGs) 2030, investment is needed in policies to promote²⁷:

Walking
Cycling
Sport
Active recreation and
Play

Building on the Bangkok Declaration on PA,¹⁰¹ the WHO states that policy actions to reverse current trends in PA require “a strategic combination of ‘upstream’ policy actions aimed at improving the social, cultural, economic factors that support physical activity, combined with ‘downstream’, individually focused approaches.”²⁷

Influencing Behavior From the Top-Down Upstream factors and interventions are key to a long-term sustainable, efficient, and agile approach.¹⁰² Better health care is only part of the solution. New research in cancer and heart disease shows that trading your car for more physically active forms of travel reduces the risk of all causes of cancer and heart disease mortality.¹⁰³ If we look at the environment, “Instead of building highways, knocking down apartments for parking lots… mayors need to be charging drivers to enter cities, approving affordable housing near transit hubs, eliminating parking requirements, and building out a robust bus network.”¹⁰⁴ Policies aimed at influencing “social institutions and norms that shape the actions of individuals” may be more effective than those “pertaining to an individual’s capacity to make the choice to act.”²¹ For instance, “if packaged foods had reduced salt content, then individuals would not have to consciously engage with any information or actively change their behavior.”²¹ We speculate that an inactivity analogy could be providing safer bike paths to nudge increased PA.

When giving behavioral nudges how we set goals is crucial. They should be achievable.¹⁰⁵^,¹⁰⁶^,¹⁰⁷ According to Milkman and Duckworth,¹⁰⁶ “Recent research suggests setting ambitious goals with some wiggle room is particularly valuable. For instance, give yourself a ‘free pass’ if you, say, miss 1 or 2 days of exercise 1 week when aiming to work out daily. You can create workout goals that are ambitious, but be sure to let yourself off the hook if you occasionally fall just shy of them.”

The WHO’s global recommendation on PA for adults is 150 minutes of moderate-intensity activity (or equivalent) per week (see Table 1.10),²⁷ including from work, travel (walking and cycling), and recreation (including sports). For adolescents, the recommendation is 60 minutes of moderate- to vigorous-intensity activity daily.²⁷ The question remains HOW to motivate people or structure our lifestyles so this is more likely to be achieved.

Table 1.10 Recommendation on Physical Activity for Adults²⁷

150 minutes of moderate-intensity activity per week (raised heart rate, feel warmer, breathe faster) (minimum of 30 minutes at least 5 days per week)

75 minutes of vigorous-intensity activity per week (difficulty talking, rapid breathing) (minimum of 25 minutes at least 3 days per week)

plus

Resistance (strength) training 2 days per week or balance exercise twice per week
For lowering blood pressure and cholesterol—An average 40 minutes of moderate- to vigorous-intensity aerobic activity three or four times per week

From AHA. American Heart Association recommendations for physical activity in adults and kids. https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults; Garber CE, Blissmer B, Deschenes M, Franklin B, Lamonte M. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359; American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 10th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2017.

The inactivity crisis is related to obesity, diabetes, and LBP. There is no simple solution but involves all stakeholders to participate. Moseley states, “A revolution in understanding of back pain is clearly required but we need a whole community approach to make it happen.”⁴² This is occurring in the cardiometabolic space as it pertains to the double whammy of eating too much and moving too little.⁸⁸ An upstream approach is needed so as to make positive lifestyle choices into one’s daily routine: “As environmental interventions become incorporated into structures and systems they have the potential to sustainably make the healthy choice the easy choice.”¹⁰⁸^,¹⁰⁹^,¹¹⁰

Another example is public investment in community spaces for activities that are either free or more affordable. Free access to fitness centers was associated with a 64% increase in attendances at swimming
and gym sessions.¹¹¹ It was also associated with an additional 3.9% of people participating in at least 30 minutes of moderate-intensity gym or swim sessions during the previous 4 weeks (95% confidence interval 3.6-4.1).¹¹¹ This was found to be especially beneficial for the more disadvantaged socioeconomic group.¹¹¹

Bauman et al’s approach ties together many social factors: “Ecological models take a broad view of health behavior causation, with the social and physical environment included as contributors to physical inactivity, particularly those outside the health sector, such as urban planning, transportation systems, and parks and trails.”¹¹²

Enhancing access and improving the efficiency of scalable solutions could result from leveraging Web-based technologies or wireless devices to help facilitate adoption of certain behavioral strategies.⁴⁴ This could help bridge the gap between the rich and poor where those who are at a social disadvantage are also at a health disadvantage.¹¹³ Health inequalities are particularly unjust because the knowledge exists to reduce the impact of lifestyle-related disorders, yet social inequalities trump knowledge dissemination.¹¹³

Precision preventive medicine aimed at promoting lifestyle changes requires a scalable national plan.²⁷ There is great diversity in how people can become more active, in particular, in which settings participation can be encouraged. Public policy must address the great variability of ways in which participation can be encouraged.²⁷ Table 1.11 lists some of these.

The adaptive predictions used in an app enable precise feedback “not only tailored to the user’s physical and social context and beliefs, but also communicated in a way that fits the user’s preferences.”⁸⁸

Table 1.11 “Upstream” Determinants of Physical Activity

Individual
- knowledge
- personal preferences
Sociocultural
- family context
- societal values
- traditions
- economic and physical environments

From The Bangkok declaration on physical activity for global health and sustainable development is a consensus statement from the 6th Congress of the International Society for Physical Activity and Health (ISPAH) on 19th November 2016. ispah.org/resources

These individual and sociocultural determinants provide a frame of reference for the diversity of opportunities for participation, which can encourage PA and improve health.¹¹³ According to the WHO, “… ‘upstream’ population-based policy approaches to promote physical activity must be prioritized and interlinked with policy actions focused on ‘downstream’ individually centered interventions” (see Fig. 1.6).²⁷

Social integration of upstream behavioral nudges requires a blending of public policy, preventive health care economics, vested interests, community health initiatives, and HCPs. According to Berkman,¹⁰ “a conceptual model of how social networks impact health” is a starting point. Social integration influences health beginning from the macrosocial and progressing to the individual person-centered psychobiologic processes. Berkman states, “We start by embedding social networks in a larger social and cultural context … upstream …. We then move downstream to understand the influences network structure and function have on social and interpersonal behavior.” The four primary pathways that influence behavior are:

provision of social support;
social influence;
social engagement and attachment; and
access to resources and material goods.

Key components of an upstream strategy (according to the WHO) include²⁷:

Large-scale participation initiatives in public spaces
Free access to enjoyable and affordable, socially and culturally appropriate experiences of PA
Integrate urban and transport planning policies to “make” increased activity in urban areas

Promote walking, cycling, and other forms of mobility

Figure 1.6 Social model of health. Reprinted with permission from Dahlgren G, Whitehead M. Policies and Strategies to Promote Social Equity in Health. Stockholm, Sweden: Institute for Futures Studies; 1991. https://www.iffs.se/policies-and-strategies/.

Promote the use of public transportation
Improve the availability of high-quality physical education to promote health and development of physical literacies
More availability for recreation, sports, and play for girls and boys
Reinforce lifelong participation and activity according to capacity and ability

The WHO states, “All countries should implement ‘upstream’ policy actions aimed at improving the social, cultural, economic and environmental factors that support physical activity combined with ‘downstream,’ individually focused (educational and informational) approaches that should be implemented consistent with the principle of proportional universality. This systems-based approach should enable countries to identify a strategic combination of recommended policy solutions tailored to context for implementation over the short- (2-3 years), medium- (3-6 years) and longer-term (7-12 years)” (see Fig. 1.7).²⁷

When designing interventions aimed at behavior change, such as increasing activity, all stakeholders should be involved at the outset in planning.⁸⁸^,¹¹⁶^,¹¹⁷^,¹¹⁸^,¹¹⁹ “Community projects or multilevel interventions that have involved the target group from the start, taking a bottom-up approach, are generally more effective in reaching those most in need of the intervention.”⁸⁸ In this way the intervention is more likely to focus on “behaviours or settings that are meaningful and feasible to the target group.”⁸⁸

In the instance of primary prevention of injuries in individuals already active or embarking on beginning an activity, certain screens have been shown to be effective.¹²⁰ It has been shown that generic preventive interventions given to an entire group are more effective than screening for individual risk factors and then offering “targeted interventions” for “at-risk” individuals (see Table 1.12).¹²⁰

Primary preventive approaches (preventing acute injuries or episodes in pain-free individuals) are appealing from both a cost-effective and efficient implementation standpoint. The role of precision medicine and individualized approach is required for the person with a past history of pain or injury or someone currently suffering an episode.¹²¹^,¹²²^,¹²³^,¹²⁴ “The optimal intervention approach may be individual in nature. To maximize their effectiveness targeted group prevention strategies may require individual customization on the basis of individual levels and variability of risk factors (e.g., past history or pain/injury^*) over time (and possibly their interaction).”¹²³

Figure 1.7 Whole-of-government solutions for physical inactivity. Reprinted with permission from World Health Organization. Global action plan on physical activity 2018-2030: more active people for a healthier world. http://www.who.int/ncds/prevention/physical-activity/global-action-plan-2018-2030/en.

Table 1.12 Group Prevention More Effective Than Group Screening Followed by Individualized Prevention

To validate a screening test to predict and prevent sports injuries, at least three steps are needed: Step 1: A strong relationship needs to be demonstrated in prospective studies between a marker from a screening test and injury risk.

Step 2: The test properties need to be examined in relevant populations, using valid measurements.

There are a number of tests demonstrating a statistically significant association with pain/injury/disability risk (see Chapter 4), and therefore help the understanding of causative factors; such tests in and of themselves are unlikely to prevent future problems.

Step 3: Document that an intervention program targeting “at-risk” individuals is more beneficial than the same intervention given to a heterogeneous group.

Currently there is no primary prevention study showing that group screening for musculoskeletal injury/pain/disability risk can lead to successful targeted, individualized preventive strategies.

Screening of past medical history can reveal those at higher risk by virtue of them having suffered previously from relevant pain or injury.
However, when preventive measures (i.e., sport or activity-specific training) is given preventively “even in the group without previous injury, the preventive effect was substantial.”

From Bahr R. Why screening tests to predict injury do not work—and probably never will…: a critical review. Br J Sports Med. 2016;50:776-780.

The Role of the Individual and HCP

Resilience Resilience is defined as “effective functioning despite the exposure to stressful circumstances and/or internal distress” (such as chronic pain).¹²⁵ A resilient person is less likely to catastrophize their pain or exhibit pain-related fear. Positive attributes such as optimism and healthy coping skills independently predict positive outcomes.¹²⁶

Factors relating to adaptive versus maladaptive functioning don’t simply represent two sides of the same coin.¹²⁵^,¹²⁷^,¹²⁸ An emerging distinction is between recovery (i.e., treatment) and sustainability (i.e., prevention). Sustainability relates to positive outcomes and has largely been ignored in pain and disability research. In a dual-factor model, recovery is the absence of negative beliefs and emotions, whereas sustainability is the presence of positive beliefs and emotions.¹²⁵ Risk or failure to recover leads to disability and distress, whereas sustainability is related to positive outcomes like participation and psychological well-being¹²⁵ (see Table 1.13).

The sustainability focus is related to the framework of positive psychology.¹²⁹^,¹³⁰ Positive psychology contends that positive, healthy aspects of life are not simply the opposite of distress and dysfunction. Sustainability can be viewed through this lens as positive coping and maintenance of participation in the presence of pain. Positive emotions can serve as a buffer against negative qualities such as catastrophizing or stress.¹³¹ An approach emphasizing positive psychology interventions does not require a mental health professional for supervision and can even be provided via online means.¹³²

A positive approach may enhance persistence and self-esteem.¹³³ In this approach, shared decision making, promoting autonomy, and providing a rationale explanation for the why behind the what is patient-centered.¹³³ According to Moseley, “Education is a missing link that would actually make advice to be active … a sensible strategy for back pain.”⁴² When people understand their pain, they become more active and have significant reductions in pain and disability.¹³⁴

Table 1.13 Definitions According to Goubert and Trompetter

Recovery “… the ability of a person to regain physical and psychological equilibrium and homeostasis following or during prolonged stress … targets the stressor, in this case pain, and focuses on the negative deviations from prior functioning that arise from pain suffering and the extent to which one is able to minimize these deviations.” Sustainability “is the ability of a person to move towards long-term positive outcomes in life in the presence of adversity.”

From Goubert L, Trompetter H. Toward a science and practice of resilience in the face of pain. Eur J Pain. 2017;21(8):1301-1315.

Figure 1.8 A resilience approach to preventing chronic pain. From Goubert L, Trompetter H. Towards a science and practice of resilience in the face of pain. Eur J Pain. 2017; 21(8):1301-1315. © 2017 European Pain Federation-EFIC®. Adapted by permission of John Wiley & Sons, Inc.

According to Goubert and Trompetter, “From a resilience perspective, health must always be considered from a dual perspective that includes both recovery (i.e., from disability, depressive symptoms, etc.) as well as sustainability of the good in life (i.e., by engaging in values-based, meaningful activities)”¹²⁵ (see Fig. 1.8). “Depending on the stressor one is faced with, more or less emphasis can or needs to be placed on either recovery or sustainability” (author’s emphasis).¹²⁵ The bottom line is that most of the emphasis in the BPS model has been on identifying risk factors of recovery and preventing or addressing them, rather than on assessing for the absence of positive factors of sustainability and promoting them.¹²⁵

A perfect example of this is that regular visits to a Physical Therapist may have unintended consequences.
This is why a focus on self-management and autonomy has such potential as a high-value approach.⁶ Moseley states, “the glaringly obvious cornerstone of best practice care that somehow keeps flying under the radar is education.”⁴²

Negative feedback has been utilized to enhance the effectiveness of the BPS model.⁴ This should create context and improved understanding for the patient. The recovery/sustainability dichotomy can be viewed as an example of this, where a recovery focus creates a negative feedback to lead practitioner and patient to a more sustainable mindset. The negative feedback mechanism “describes an ongoing, dynamical interplay between the individual and the environment.”⁴ Negative feedback moves the system closer to equilibrium or its reference state, in other words, perception tends to drive behavior. “Negative feedback clarifies this apparent anomaly by explaining that it is the discrepancy between the goal and the currently perceived state that directs actions, not the goal itself.”⁴ “Successful therapy could be defined as a process of enabling people to acquire skills and knowledge so that they can keep important variables in their reference states.”⁴ The goal of a negative feedback is to reduce errors or discrepancies between the current state and their reference state. When a patient is experiencing distress they are in a maladaptive situation, which is moving them away from equilibrium. The goal of integrating negative feedback into the BPS model is to influence perception and a keep it closer to its reference level. Social determinants of health and negative feedback are linked by control. “What is likely to be the critical factor in social conditions affecting health is the extent to which people are able to reduce the gap between their experiences and their expectations in an efficient and ongoing manner.”⁴

The HCP’s Role In our current chronic pain and disability management system, downstream approaches still dominate. A fundamental problem for EBHC is the HCP’s difficulty in changing paradigms.¹³⁵ Transitioning from a biomedical to a BPS approach is challenging.¹³⁶^,¹³⁷^,¹³⁸ Changing knowledge, beliefs, and attitudes occurs easier than actual practice changes.¹³⁹^,¹⁴⁰^,¹⁴¹

Dissemination of EBHC has occurred but implementation lags behind.³^,⁵^,⁶ Ostelo developed a screening questionnaire for clinicians to determine their orientation (biomedical vs. BPS).¹⁴² The biomedical orientation is in line with persistent back pain myths. These include the need for an accurate diagnosis of the structural cause of pain, the need to rest until pain is gone, and the belief that medication or passive care approaches are required. Houben et al showed that this screening tool indicated that clinician orientation predicts both the clinician’s harmfulness ratings of PAs and their recommendations for PA that they give their patients.¹⁴³

Figure 1.9 The prerequisites for therapeutic alliance. Reprinted with permission from Miciak M, Mayan M, Brown C, Joyce AS, Gross DP. The necessary conditions of engagement for the therapeutic relationship in physiotherapy: an interpretive description study. Arch Physiother. 2018;8:3.

So that more upstream strategies can be integrated into the current system, certain traits of the HCP may be beneficial to inculcate. Four conditions have been identified as necessary for forging a therapeutic alliance with patients—present, receptive, genuine, and committed (see Fig. 1.9).¹⁴⁴ These incorporate the intentions, attitudes, and communication skills of the HCP.¹⁴⁴

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