Challenges to decrease the burden of spinal pain

The global health burden of musculoskeletal conditions is increasing with spinal pain conditions such as low back and neck pain contributing significantly to this burden(1). Physiotherapists have led the way in the research and investigation of both the underlying and contributing mechanisms as well as treatments for spinal pain conditions. Despite this research effort, few effective interventions have been identified with many showing only modest effects at best on health outcomes whether they be pain, disability or functional outcomes. Treatment approaches developed in response to identified processes such as joint dysfunction, neural tissue contributions, muscle changes and motor control disturbances held great promise but show mostly equivocal results. Educational approaches that teach patients about neurophysiology and techniques aiming to ‘train the brain’ are the new black but their effectiveness or otherwise are yet to be fully evaluated.

When a trial of physiotherapy is shown to be ineffective or at best modestly effective, there is an almost palpable inward drawing of breath throughout the profession. Various hypotheses are put forward to explain the results including that the treatment was not ‘right’; randomised controlled trial (RCT) study designs are not optimal to detect the effects of treatment; the outcome measures used are non-responsive (despite all outcomes in a trial showing little change); or that we need sub-groups of patients to be identified and then it will all work out and the true beneficial effects will be realised.

Some of these arguments may have some merit, but there is another argument. If we are to be perfectly honest, perhaps the treatments in question are in fact not very effective. If this is the case, at some point in the future, the profession will have to confront this issue. Instead of being threatened, perhaps as a profession we need to embrace the evidence and take on the challenge of improving health outcomes for people with musculoskeletal pain. The people with pain must be the central issue in this debate. For example if for patients with acute whiplash, receiving a single physiotherapy session is as effective as receiving six(2), isn't this good for the patients, as well as the health system as a whole? There is less burden placed on patients to attend for more visits and either they personally or the health or insurance systems are saved costs. (This ultimately means we as tax payers are saved as well).

So as the burden of musculoskeletal and spinal pain increases, we are left with little ammunition to prevent this barrage. What is the answer to spinal pain conditions? This is a huge challenge to both physiotherapy research and clinical practice. I don't profess to have the answer to this dilemma but I propose some observations that may be useful to stimulate discussion.

Is it the case that we still don't understand the processes involved in the initiation and maintenance of spinal pain? Have investigations in this area been stymied by the popular conception that there is usually no pathoanatomical or peripheral reason to explain persistent spinal pain? Low back pain is labelled non-specific and it is commonly assumed that whiplash injury involves no specific peripheral lesion or injury(3). It is almost politically incorrect to mention the word ‘peripheral pathology’ for fear of being labelled a ‘peripheralist’ as one who has little understanding of such in depth and complex issues as pain. Yet on the other hand, what is the advantage to patients in being able to identify peripheral nociceptive sources? How would this change the management of spinal pain? Aside from some structures such as the cervical zygapophseal joint, most spinal structures are not able to be successfully anaesthetised. It is likely that this situation could perpetuate frustration and feelings of helplessness in patients with a diagnosed pathology. This is not a reason to avoid conducting research in this area as the identification of specific pathologies may then drive the development of more successful interventional techniques. Further to this, even if patients report decreased pain following such interventions, they still need to be able to move efficiently and return to their optimal level of function, so the role of physiotherapy remains important. It is the combination and integration of both approaches that could have potential to improve health outcomes.

Other processes have been identified as potential contributors to spinal pain and to the development of a chronic condition. Augmented central nervous system nociceptive processes which are found in many musculoskeletal conditions and are associated with poor recovery following whiplash injury(4). Whilst the modulation of these processes may improve health outcomes for spinal pain, to date this has not been well investigated. Physiotherapy techniques, whether that be manual techniques, exercise or other modalities, are likely not to be sufficient to attenuate central hyperexcitability but physiotherapy combined with medication directed at these processes may be a potent combination that warrants investigation. Research of genetic markers also has the potential to shed light on processes underlying spinal pain conditions. Early evidence indicates that variants in genes associated with stress responses to trauma are associated with greater severity of pain and psychological symptoms in the early weeks post whiplash injury(5). This may indicate that individual vulnerability factors influencing the function of the stress system may contribute to the development of chronic whiplash pain. Such research allows for improved understanding of processes contributing to the development of chronic pain. Physiotherapy interventions may need to account for these factors and include methods to address stress related responses (in this case) into the usual physiotherapy predominantly exercise based care for acute whiplash.

Some areas of physiotherapy are beginning to explore these issues. Trials are emerging that combine physiotherapy approaches of exercise +/- other physical techniques with cognitive behavioural approaches delivered by physiotherapists that aim to address some of the psychological factors shown to be common in patients with spinal pain and other musculoskeletal conditions. Some of these trials are showing promising results. However there will be psychological conditions present in some patients, that physiotherapists are not equipped to deal with. Examples of this include posttraumatic stress disorder in people with chronic whiplash and depression in all spinal conditions. In this case, the physiotherapist will need to first identify that such psychopathology may be present and then instigate referral as necessary, thus taking a broader responsible role in the overall care of patients with spinal pain.

In the wake of the passing of two great physiotherapy innovators, Bob Elvey and Robin Mckenzie, we also need to innovate and improve the practice of physiotherapy for spinal pain. This does not necessarily mean that we need to develop new manual techniques or exercises or find ‘new’ muscles that need retraining. It may be that we need to look more broadly and take account of processes and factors that physiotherapists don't usually include as part of their skill set. Physiotherapists are ideally placed to take on more of a ‘gatekeeper’ role in effectively managing the overall care of people with spinal pain. This would mean identifying patients who may benefit from the integration of care from other health professionals into their plan of care if physiotherapy alone is not improving the patient's condition. Then, thoughtfully assisting the patients through this minefield. Equally important is to identify patients who require only minimal care and providing just this – fewer treatments.

Physiotherapists can play a key role in reducing the burden of spinal pain; let's make that a leading role in both the research and clinical management of such conditions.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.