Chronic back painBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6964.1304a (Published 12 November 1994) Cite this as: BMJ 1994;309:1304
EDITOR, - Michael I Jayson's editorial on the causes of chronic back pain is to be lauded for two reasons.1 Firstly, it emphasises the disparity between clinically demonstrable findings and subjective complaints of pain: the wider the acknowledgement that a minor abnormality evident in a scan or x ray film may be coincidental to the complaint of pain the less harm will be done to backs by treatments based on attempts to correct innocent lesions. Secondly, the editorial supports the growing realisation that while peripheral nociception cannot account for many of the clinical symptoms of chronic back pain, disordered central neural processing can.
Unfortunately, Jayson fails to cross other, arguably more important, conceptual divides. The real challenges of back pain lie in channelling medical endeavour from a purely biomedical perspective (be it peripheral or central) to a broader model incorporating social and psychological perspectives. The real divides we need to bridge are from brain to psyche, from biomedicine to holism, and from point aetiology to process.
Searching for a lesion in a different part of the nervous system is the easy way out: we prolong the denial of our therapeutic impotence by ordering other expensive investigations. Meanwhile the patient becomes ever more convinced that he or she has a demonstrable, and presumably treatable, lesion. When the patient finally realises that this is not the case the anger and frustration caused by years of misinformation make rehabilitation even more difficult.
The mountain of disability caused by back pain stands a chance of being levelled only when doctors can translate the broad canvas of the epidemiological picture to the difficult patient sitting in front of them. This nearly always means diminishing the conviction of disease, encouraging normal function with advice and rehabilitation, and doing not more investigations but fewer.