Dennis C. Turk, PhD, is a psychologist and the John and Emma Bonica Professor of Anesthesiology and Pain Research at the University of Washington in Seattle. Turk’s research has explored chronic pain related to a number of conditions including migraine, fibromyalgia, and temporomandibular joint disease, as well as low back pain. He served on a panel convened by the federal Agency for Healthcare Policy and Research (AHCPR) to develop clinical practice guidelines for acute lower back problems in adults. [3]

Q: Is low back pain a major health problem?

A: It's one of the most significant problems in medicine right now, not only from the standpoint of the volume of people affected, but also in terms of the amount of disability it causes and the costs associated with treatment and lost wages.

Q: Does back pain occur more frequently in some people than in others?

A: It seems to be just as common among women as men, unlike many other chronic pain conditions, which are more prevalent in women. And despite what one might think, there is no good evidence that the nature of the work you do– say as a construction worker – leaves you at greater risk for back pain. In some respects they might be in better shape than me sitting here at my desk, which puts more pressure on my spine than standing up or lying down. But if I have back pain, it is a lot easier for me to go back to work. If I am a construction worker or a factory worker on an assembly line, I may have less flexibility to adjust my work duties or get up and move around if my back hurts. So disability from back pain is frequently more of a problem in some lines of work than others.

Q: When people talk about back or other pain, they frequently divide it into three types: acute, recurrent, and chronic. What do those terms mean?

A: There's a time when the pain is acute, meaning of short duration, when it is recurrent, meaning it returns after a previous episode, and when it is chronic, meaning that it lasts for a long time. In the AHCPR guidelines, we defined acute back pain as lasting three months or less; anything that goes longer than that is a chronic problem. Most people with back pain don't have chronic pain – they have periodic episodes. They hurt their back, they get better after a couple of weeks and go back to their usual activities, and then they have flare-ups. Once you've had your first episode of back pain you are predisposed to new episodes.

Q: Do we know what causes acute episodes?

A: There are certain red flags that we look for. If you have a trauma, such as falling off a ladder, you might have x-rays or another imaging procedure to rule out a fracture. If you have a history of cancer, then it's possible there is a new tumor. If you have lost bowel or bladder function, or display signs of a "foot drop" – where the patient cannot lift his or her forefoot when walking – there might be neurological involvement. Infection is another red flag. But once these things are ruled out, the bottom line is that in 80-85 percent of people with back pain, there's no objective physical pathology that's ever identified. [6]

Q: At one time it seemed quite common for people to have surgery for a herniated disk. Is this still the case?

A: It’s still common. "Herniated," however, is a bad term. It’s still common to have surgery for a herniated disk. "Herniated" is a bad term. It makes it sound like something has burst or broken, and it causes people a lot of fear. There are some people in pain who have a disk impinging upon the nerves and who may benefit from surgery. But there are lots of people – somewhere in the neighborhood of 30 percent – who display herniated disks or other significant pathology on MRIs or other imaging procedures, but they have no symptoms or pain. So simply having a herniated disk is not a reason to have back surgery. We concluded in the AHCPR guidelines that only two percent of people require surgery for back pain in the acute stage. But there are about 250,000 people who have back surgery each year at a cost of about $15,000 each. Many of these procedures may be unnecessary.

Q: You and others advocate a collaborative, team approach to treatment for chronic back pain that employs physicians, psychologists, and other specialists, and encourages patients to take part in their own care. Why?

A: Among people who visit a pain clinic for chronic low back pain, the pain has lasted for an average of seven years. In that time, back pain has come to impact all aspects of their lives – social activities, family activities, work, and recreation. As the pain persists, they become more anxious and depressed, engage in fewer activities, spend less time on a job or quit working, become withdrawn, and now focus on their pain. The likelihood that any one specialist – the best physical therapist, or the best neurologist, psychologist, or occupational therapist – could take care of all their problems is pretty slim. That’s when a comprehensive approach, taking into account a range of medical, social, and psychological factors becomes key, both from the standpoint of assessing the problem and in treating it. A number of rigorous studies have shown that this multidisciplinary approach to chronic low back pain and other chronic pain conditions is superior to usual care in terms of reducing pain and medication use and increasing activity and returning people to work. [7]

Q: How do patients become more involved?

A: We teach people to think about "rehabilitation" rather than "cure." Cure means you would go to a health-care professional who would "fix" the pain. Rehabilitation means you're going to learn to pace your activities and to keep active to increase your strength and endurance and prevent pain flare-ups. You also are going to learn relaxation or distraction techniques to cope with pain flare-ups and learn how to combat negative attitudes that promote anxiety and depression, which may exacerbate your pain. And you are also going to learn how you can interact and communicate differently with both your family and your health care providers in ways that lessen your dependence on them and allow you to function better despite some continuing discomfort. The goal is to find ways to help people become much better self-managers of their own condition.

Interview #2: 'The Collaborative, Team Approach to Chronic Back Pain'

Judith Turner, PhD, is the Hughes M. and Katherine G. Blake Professor of Health Psychology at the University of Washington School of Medicine in Seattle and is affiliated with the Department of Psychiatry and Behavioral Sciences, the Department of Rehabilitation Medicine, and the Multidisciplinary Pain Center there. Turner has conducted research on chronic low back pain and other chronic pain conditions since the mid-1970s.

Q: How does a collaborative, team approach to chronic low back pain work?

A: The first step is a comprehensive assessment and evaluation. At most pain centers it includes evaluations by a physician and a psychologist. For people who seek to return to work, evaluation by a vocational rehabilitation counselor may also be useful. The evaluating practitioners discuss the factors contributing to the patient’s pain problem and offer him or her a recommended course of treatment. Treatment typically includes education about back pain including causes and treatment options; techniques to help them cope with it; individual or group psychotherapy to address depression, anxiety, or relationship issues that may be caused by or contributing to the problem; physical therapy to improve strength and endurance, with the goal of returning to usual activities; medication management; and vocational counseling to facilitate return to work or school. The goal is to try to work with the whole person and address every factor that may be contributing to his or her chronic back pain problem.

Q: How does this approach differ from what might happen if I simply visited a primary care physician for my chronic low back pain?

A: A collaborative, team approach allows several different treatments addressing different aspects of the pain problem to be delivered at the same time, in a coordinated manner, with daily communication among the treatment providers and the patient. If you visited your primary care physician, he or she would have to refer you to other providers in other settings for specialized evaluation and treatment. For example, your primary care doctor might refer you to an orthopedic surgeon, who may decide this is not a surgical problem, and refer you for physical therapy. Continued communication and coordination of care between the primary care doctor and the physical therapist and the orthopedic surgeon is probably not going to be ideal. If a problem develops and the physical therapist is considering slowing the pace of treatment, he or she may not have ready access to the physician for consultation. This becomes especially important for patients with chronic low back pain because it is frequently longstanding and so many problems may be involved. For example, physical therapy can be very helpful, but if other factors such as work dissatisfaction or serious depression are involved, treatment that does not address these factors is very likely to fail. On the other hand, psychotherapy alone without a program to get back into shape physically and return to work and usual activities is not likely to be effective either.

Q: You’ve talked about the importance of collaboration among health care providers. How do you get patients to collaborate in their own care?

A: Everything we have learned about chronic back pain tells us that it is very likely to continue over some time, and even when it gets better, it is likely to recur over time. That means, that like any chronic medical condition, you always need to be thinking about skills that patients can use to manage the symptoms on their own. It is important for health care providers to let their patients know this and to help them learn how they can effectively participate in their own care. A number of randomized controlled trials have shown that patients with chronic pain who learn cognitive behavioral techniques are highly effective in reducing their pain and decreasing their disability. [15] There is even some evidence that patients who learn these techniques after an acute episode of pain may be less likely to develop a chronic pain problem. [13]

Q: How do these techniques work?

A: Most treatments begin by trying to change people's attitudes toward their illness. In back pain, people need to understand that resting and lying around and waiting for their back to heal is not helpful and in fact may be harmful. Somebody in extreme pain may not be able to do a whole lot, but we want people to resume their usual activities as soon as possible. They also need to learn that when they try to do more they may feel pain, but it is not a signal that there's tissue damage and they need to rest. Finally, they have to be realistic about their pain. They probably can’t expect their pain to totally disappear right away, but they can learn to get on with their lives.

Q: What else does the treatment include?

A: The behavioral treatment focuses on helping patients gradually and systematically increase their activity. People with chronic back pain give up quite a bit in terms of doing household chores, yard work, and social and recreational activities. They may not be able to sit for long periods of time, so they avoid going out to a movie or a restaurant. We help patients identify specific behavioral goals that are important to them – whether it's playing golf or cooking dinner. We break it up into small component steps and work out a plan where you gradually go from step to step to reach the goal.

Q: You mentioned teaching patients how they can learn to control and live with the pain. How do you do that?

A: One strategy is to change the things people say to themselves when they experience a flare-up of back pain. We teach them to recognize negative thinking that can increase their levels of stress, anxiety, and depression. So instead of saying, "I can't take it anymore, nothing works," they might say, "Okay, I know I am feeling discouraged now, but the doctors told me this might happen, and maybe I could use one of the strategies they taught me." These strategies might include progressive muscle relaxation to reduce muscle tension, pain, stress, and anxiety, as well as guided imagery or other distraction techniques that help them focus on something other than the pain.

Q: How important are family members and others?

A: Spouses and other family members can play critical roles. Sometimes spouses can be well meaning but inadvertently undermine recovery by reinforcing patients’ pain behavior. For example, if spouses intervene every time patients try to do something for themselves, patients may make fewer attempts over time and gradually become more disabled. [18] On the flip side, family members can be extremely helpful allies. In one successful chronic pain program for people with osteoarthritis, for example, spouses come into the treatment sessions with the patient so they can learn how to help them in their daily activities and encourage them to stick with their treatment program even when they get discouraged. [12]

Back Pain in Children

Back pain frequently is thought of as a problem for adults, but experts increasingly recognize that children also experience back pain – and there is some evidence it may signal the potential for recurrent problems in adulthood.

French researchers, for example, surveyed 123 eighth-grade boys and girls and found that more than 83 percent had experienced some back pain in the past year. [22] Sixteen percent reported a single episode, 58 percent reported recurrent pain, and nine percent reported chronic back pain. In 19 percent of cases, children visited a doctor, and in 15 percent they had missed school or sports.

One of the strongest predictors of back pain turned out to be the weight of the children’s book bags. Children whose book bags weighed 20 percent or more of their body weight were three times more likely to report back pain than were those with lighter bags.

There is conflicting evidence, however, whether back problems in childhood predict back problems in adulthood. Finnish researchers have found that when children with back pain have early signs of spinal disk abnormalities, they are at increased risk of recurrent back pain as young adults. [19] Among 14-year-olds followed for nine years, those with evidence of spinal disk degeneration were 16 times more likely to report recurrent back pain through their early 20s.

However, Danish researchers who followed 640 school children for 25 years say spinal abnormalities did not predict who went on to develop low back pain in adulthood, but having a family member with back problems or experiencing back pain in childhood did. [11]

Surgery for Back Pain

U.S. surgeons performed more than half a million surgical procedures on the back in 1996 (the latest year for which figures are available), including 324,000 operations to remove or destroy a damaged disk; 192,000 procedures to fuse adjacent vertebrae; and 125,000 procedures to remove the lamina (roof) of one or more vertebrae. [17] No one is certain exactly how many of those procedures may have been unnecessary, says Dr. John D. Loeser, a neurosurgeon at the University of Washington, Seattle , because there is "no gold standard" regarding which surgical procedures for back pain are optimal and how frequently they should be utilized.

Research by Loeser and colleagues, however, suggests that people in the United States are significantly more likely to receive back surgery than their counterparts in other developed countries. [4] The researchers found that back surgery was performed at a rate that was at least 40 percent higher than that performed in 11 other developed countries and five times higher than in England and Scotland. The researchers also found that the rate of back surgery varied from country to country in almost direct proportion to the numbers of orthopedic and neurosurgeons practicing there.

"Back surgery rates remain high in the United States because there is very strong peer pressure in our profession, as in many others, to do what everyone else seems to be doing," Loeser says. "The big issue is a lack of knowledge about the natural history of the condition and a lack of knowledge about the efficacy and outcomes of available treatments."

That lack of knowledge contributes to wide variations on a local and national level in the number of back surgeries performed. In another study, Loeser and colleagues found that hospitalizations for back surgery occurred at twice the rate in some regions of the country compared with other regions. [23]

Efforts to educate physicians and alter their behavior have been controversial. This was the case when the federal Agency for Health Care Policy and Research issued guidelines on the treatment of acute low back pain in adults. [3] Those guidelines generally ruled out surgery for low back pain within the first month of symptoms unless there was evidence of serious spinal defect and severe debilitating symptoms. The guideline recommended against spinal fusion surgery (an operation that "welds" two vertebrae together) within the first three months of symptom onset. These recommendations were met with vocal dissent from a group of specialty orthopedic surgeons, spinal device manufacturers, and others.

One way to alter the rates of back surgery performed may be to target patients. That’s what Dr. Richard Deyo, an internist at the University of Washington, Seattle, and colleagues did when they created an interactive videodisc program for low back pain patients. [21] The disc included descriptions of various surgical and non-surgical treatments, tables summarizing their risks and benefits, and interviews with patients. A key feature of the disc was its interactive format, which allowed patients to zero in on information tailored for their age and specific diagnosis, Deyo says.

Patients who watched the videodisc felt better informed and demonstrated more knowledge about back pain than did a comparison group who did not see the videodisc. They were also less likely to choose to have surgery but achieved similar levels of pain relief and ability to function over time, Deyo says.

The videodisc has been adapted to a videotape format and is available from the Foundation for Informed Decisionmaking, a nonprofit group based in Hanover, NH. [8,9]

Education, Support Just an E-Mail Away

Can an e-mail discussion group help back pain patients reduce their pain and disability?

That is one of the questions Dr. Kate Lorig hopes to answer in a two-year randomized study with 600 back pain patients. With a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, Lorig has created an e-mail discussion group where back pain patients can share information and experiences. Participants subscribe to an e-mail list (called a "listserve"), and when they pose a question or make comments, these are forwarded via e-mail to every other person on the list. A physician, a psychologist, and a physical therapist comment on the discussions and serve as resources for further information.

The group has discussed conventional and alternative treatments for back pain, including surgery, chiropractic treatments, and magnets. They’ve also traded experiences learning new coping skills, such as action planning and problem solving, and exchanged tips on travel, sleep, and shoes.

Lorig says there are no restrictions on what can be discussed and no editing of comments. Everyone does need to remain courteous and respectful of one another, however. "Flaming" – the e-mail equivalent of a nasty tirade – is not tolerated, Lorig says.

Participants fill out periodic questionnaires describing their pain levels, activity restrictions, and use of health care services. Their responses will be compared with another group of back pain patients who are not participating in the e-mail discussion group. The study is approaching the halfway mark and follow-up data from sixth-month questionnaires are "promising," Lorig says.

Back Pain in Primary Care

Low back problems are the second most common symptom prompting people to seek treatment from their primary care physician. [5] While the vast majority of cases are uncomplicated, the typical 10-15 minute primary care visit frequently concentrates on ruling out the serious but rare causes of back pain – to the exclusion of advice that may prevent the pain from recurring or allow people to better cope with it if it does.

One alternative may be to offer such training and techniques as an adjunct to primary care. Michael Von Korff, PhD, and colleagues at Group Health Cooperative of Puget Sound, Seattle Washington, developed a four-session program for back pain patients that was modeled after the highly successful Arthritis Self Management Program developed by Kate Lorig, PhD, of Stanford University. [24] The program featured lay instructors, also back pain sufferers, who led participants through a broad education and skill-building program. Participants learned when to be concerned about pain and when to not. They tried relaxation and distraction techniques to help them better cope with back pain. They practiced problem-solving techniques and explored better ways to communicate with their families and health care providers. They also received copies of an educational videotape and the Back Pain Helpbook. [14]

The patients who participated in the self-management program reported fewer activity limitations over a one-year follow-up period when compared to the usual care control group. They also reported greater confidence in back pain self-care, were less worried about back pain, and expressed less fear of injury and activity relative to the control group.

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The Research:

1. American Academy of Orthopedic Surgeons. (1999). "Low back pain." Rosemont, IL. http://www.aaos.org.
2. Andersson GBJ. (1997). "The epidemiology of spinal disorder," in The Adult Spine: Principles and Practice (JW Frymoyer, ed.). Philadelphia, PA: Lippincott-Raven.
3. Bigos S, et al. (1994). "Acute low back problems in adults. Clinical practice guideline No. 14." Agency for Healthcare Policy and Research. Rockville, MD. http://www.ahcpr.gov.
4. Cherkin DC, et al. (1994). "An international comparison of back surgery rates." Spine, 19(11): 1201-1206.
   
   
5. Deyo RA and Phillips WR. (1996). "Low back pain: A primary care challenge." Spine, 21(24): 2826-2832.
6. Deyo RA. (1986). "The early diagnostic evaluation of patients with low back pain." Journal of General Internal Medicine, 1: 328-338.
7. Flor H, et al. (1992). "Efficacy of multidisciplinary pain treatment centers: A meta-analytic review." Pain, 49: 221-230.
8. Foundation for Informed Medical Decisionmaking. (1994). "Treatment choices for low back pain: Herniated disk." Hanover, NH. http://www.healthdialog.com.
9. Foundation for Informed Medical Decisionmaking. (1994). "Treatment choices for low back pain: Spinal stenosis." Hanover, NH. http://www.healthdialog.com.
10. Frymoyer JW and Cats-Baril WL. (1991). "An overview of the incidences and costs of low back pain." Orthopedic Clinics of North America, 22: 263-272.
11. Harreby M, et al. (1995). "Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults? A 25-year prospective cohort study of 640 school children." Spine, 20(21): 2298-2302.
12. Keefe FJ, et al. (1999). "Spouse-assisted coping skills training in the management of knee pain in osteoarthritis: Long-term follow-up results." Arthritis Care and Research, 12(2): 101-111.
13. Moffett JK, et al. (1999). "Randomised controlled trial of exercise for low back pain: Clinical outcomes, costs, and preferences." British Medical Journal, 319(7205): 279-283
14. Moore JE, et al. (1999). The Back Pain Helpbook. Cambridge, MA: Perseus Books. http://www.perseusbooks.com.
15. Morley S, et al. (1999). "Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain adults, excluding headache." Pain, 80(1-2): 1-13.
16. National Institute for Occupational Safety and Health. (1999). "National occupational research agenda." Atlanta, GA. http://www.cdc.gov/niosh.
17. Owings MF and Kozak LJ. (November 1998). "Ambulatory and inpatient procedures in the United States, 1996." Vital and Health Statistics, 13(139): 1-119.
18. Romano JM. (1995). "Chronic pain patient-spouse behavioral interactions predict patient disability." Pain, 63: 353-360.
19. Salminen JJ, et al. (1999). "Recurrent low back pain and early disk degeneration in the young." Spine, 24(13): 1316-1321.
20. Schappert SM. (February 1998). "Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1996." Vital and Health Statistics, 13(134): 1-37.
21. Spunt BS, et al. "An interactive videodisc program for low back pain patients." Health Education and Research, 11(4): 535-541.
22. Viry P, et al. (1999). "Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren." Revue du Rhumatisme (English ed.), 66(7-9): 381-388.
23. Volinn E, et al. (1994). "Patterns in low back pain hospitalizations: Implications for the treatment of low back pain in an era of health care reform." Clinical Journal of Pain, 10(1): 1-2.
24. Von Korff M, et al. (1998). "A randomized trial of a lay person-led self-management group intervention for back pain patients in primary care." Spine, 23(23): 2608-2615.

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

Funding for this series was provided by the Robert Wood Johnson Foundation.

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