Analysis: taking a coaching-focussed approach to back pain is effective, saves money and puts the person with pain in charge
Low back pain is so common that you are the unusual one if you have never had it! Thankfully, getting occasional back pain which settles reasonably quickly is not an unusual or dangerous thing. In fact the odd, mild episode of back pain is probably like experiencing tiredness, sadness or constipation – not pleasant, but not usually a cause for major concern.
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From RTÉ Brainstorm, all you need to know about back pain
In contrast, back pain can last for a long time or become debilitating for some people. This can have huge implications for the person affected, but also society in terms of reduced productivity. Consequently, billions are spent globally each year to try to prevent and treat back pain. However, much of this spending is arguably wasted.
Why is this happening?
For too long, we have had the wrong idea about what back pain is, and what treatments might help. For example, back pain has traditionally been viewed as a straightforward mechanical problem with structures in the back being damaged (eg discs). This perceived damage has been mostly attributed to physical factors such as sitting, bending or lifting the 'wrong' way. This is how, in fact, most healthcare professionals like physiotherapists, chiropractors and doctors were previously trained to assess and treat back pain: find the damaged structure, and ‘fix’ it through some treatment such as manipulation, massage, ergonomic advice, medication, injections or surgery.
But it is now clear that the degree of ‘damage’ (as seen on MRI scans) among people with back pain is remarkably like that seen among people without back pain. In other words, people can have significant back pain and have a perfectly clear MRI scan. Alternatively, painfree people can have an MRI scan which shows lots of stuff we used to think was a sign of damage, but is more likely a sign of normal aging, like wrinkles and baldness.
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From RTÉ Radio 1's Drivetime, what causes back pain in teenagers?
Similarly, how we bend, sit and lift is not as important as we used to believe as a cause of back pain. This is why most international guidelines recommend that people with back pain should not rush for MRI scans, as they rarely give us a useful diagnosis to ‘fix’, or seek traditional ‘quick fixes’ as commonly as they do.
So if back pain is not simply about ‘damaged’ structures that need to be ‘fixed’, what is going on? The research is clear that back pain is more likely to last a long time, and become disabling, among people whose general health and wellbeing is affected. For example, factors such as psychological (eg stress, mood, anxiety), social (eg relationships, job satisfaction, financial status) and lifestyle (eg sleep, physical activity levels, obesity) affect recovery from back pain.
What would be a better option for people with back pain?
Rather than narrowly focussing only on structures in the back, we need to look at the whole person, physically and mentally. We need to better support people with ongoing back pain to both identify, and then deal with, whatever factors are affecting their recovery – with the goal of them self-managing their back pain long-term.
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From RTÉ Radio 1's Ray D'Arcy Show, Prof Kieran O'Sullivan with advice on dealing with back pain
Interestingly, the factors that are most relevant can differ between people. This is where healthcare professionals such as physiotherapists being trained to act as health coaches can help identify the barriers to recovery, and then help the person with back pain put a comprehensive plan in place. For some people it might be mostly about improving their physical activity, sleep and diet; for others it might be through helping them plan their work-life balance to reduce stress levels and make time for healthier living.
With any major change like this, some challenges and opportunities are worth noting.
Challenges
This requires a major mindset shift. People with back pain often expect a ‘fix’ – usually one involving scans, medication or physical treatment – and offering less of these could be perceived as withdrawal of valuable services to simply save money. However, we know that excessive use of scans or medications such as opioids carry significant costs and/or risks.
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From RTÉ Radio 1's Today with Claire Byrne, Prof John Carey from Galway University Hospitals on back pain and overreliance on MRI scans
Furthermore, discussing how things such as stress and sleep are involved could sound like we are suggesting people with back pain are in some way to blame. Therefore clear communication of this shift in emphasis is needed to ensure people with back pain do not feel stigmatised or abandoned.
A similar mindset shift is needed among healthcare professionals, and health funders, so that coaching approaches are valued, and funded, even if they are less tied to individual professional identities compared to say massage, manipulation or injections.
Opportunities
Not alone have approaches like this been shown to help reduce back pain, they have also been shown to be cost-effective. Two large clinical trials published in the prestigious Lancet journal within the last year alone reinforce the potential of health coaching for back pain. One study, which combined health coaching with a simple but progressive walking programme, significantly reduced the risk of back pain recurring. Another study using a comprehensive coaching approach reduced both pain and costs for those with disabling low back pain. In these studies, the coaching was aligned with sensible exercise programmes.
In conclusion, switching to a coaching-focussed approach to back pain is effective, saves money and puts the person with back pain in the driving seat in managing their pain and health long-term. For more information see online resources such as Pain Tool Kit, Pain-ed and Restore.
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The views expressed here are those of the author and do not represent or reflect the views of RTÉ
