By NORTIN HADLER, MD
To live a year without a backache is abnormal.
Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly.
Almost all of the people we will be talking about in this book were afflicted with regional backache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.1 Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.
While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price.
An assault on the backache industry is long overdue. No reader will find all the chapters that follow resting easily with their preconceptions. Many will find some counter-intuitive, some infuriating. After all, no one has escaped backache; we all know someone who suffered mightily and probably someone whose life is burdened with a “bad back”. I am not out to rub salt in the wounds of sufferers. But I know no other way to help those yet to fall victim, and perhaps some who have, than to forcefully and directly decry the status quo and to support my assertions with the science that society has ignored.
Clinical aspects of regional low back pain and the various treatments are discussed in the central chapters. My intent is to illustrate the fashion in which the state of the science could and should inform the state of the art. There are many relevant, reproducible, quantifiable scientific assertions about back pain. Some of the science leads to assertions that are counterintuitive. Many are a reproach to “common practice.” All are difficult to implement given the common wisdom about backache. Changing attitudes and entrenched practices is never quick and easy. I am writing this book in the hope of greasing that path.
Over the ages almost every causal and therapeutic notion imaginable, and some unimaginable, has been foisted on the individual who seeks assistance in coping with a regional backache. Furthermore, often, even more often than not, the assistance coincides with relief of the pain. Few who sought a “cure” would then regard the “cure” as a coincidence. Few who are “cured” can entertain the possibility that they were fooled, that they would have done as well without the “cure.” Hence, “cures” become entrenched and over time succor their purveyors and their advocates who are certain their record of success is incontrovertible evidence that their diagnosis of the cause of the pain was valid and that the “cure” worked. On the next flair-up of back pain, the firm believer is likely to return for another ministration. And if the result is less satisfactory, he is likely to assume that this episode of back pain was worse or different from the last such that another type of treatment needs to be superimposed. In this fashion, society convinces so many people that therapists hold the solution to their current or next backache. Testing all these parallel and intertwined, yet firmly held beliefs is an enormous scientific challenge.
One of the greatest, yet unsung accomplishments of the scientific method is to have largely met this challenge. In the past twenty years, not only have many of the theories regarding the avoidance of back pain been tested, many of the proposed treatments have been systematically studied as well. None survives “unscathed,” and most have been proven untenable. Each of the central chapters examines a particular establishment committed to and succored by the present system: the physician, the alternative provider, and the surgeon. To the extent that each rests on untested beliefs, or beliefs that defy testing on methodological grounds, they are sectarian communities of providers. Many who are treated and most doing the treating balk at submitting their treatments to scientific testing. They fall back on metaphysical arguments, And they have the power and money to influence the polity and the common sense. All I can do is hope that this book will arm readers with the critical wherewithal to fend for themselves in this marketplace. I realize that the lag between the time that our preconceptions are formed and the time that we need to exercise informed choice can be many decades. All I can hope is that reason will prevail over sectarian interests and metaphysical arguments…someday.
I have several goals in writing this book that relate to health care policy. This is the first. The second relates to the notion that a regional backache is an injury. The latter chapters in the book take on this idea. Prior to the 1940s the word “injury” was not applied to a case of regional backache. One would have been no more comfortable labeling a regional backache an “injury” than a headache. This change is not simply an exercise in labeling; it is an example of a linguistic determinism that accompanied the rise of a movement for a safer workplace.
Before mid-century, almost no American worker had health insurance other than what was covered by Workers’ Compensation schemes for an injury that occurred at work. The injured worker is indemnified for medical care and salary maintenance. It is not surprising that a hernia in the groin area would soon be labeled a “rupture” qualifying as a compensable injury. Backache soon followed. I can explain these roots in empathic terms. However, labeling regional back pain an injury has afforded much advantage to the worker with regional low back pain. To the contrary, it has provided the workforce with relentless grief and the establishment committed to its perpetuation with unconscionable largesse. The phrase “I injured my back at work” and Workers’ Compensation indemnity schemes go hand-in-hand. In the past two decades, the relationship has been carefully and scientifically explored, and the results are clear. The final chapters dissect: the ergonomic fallacy, the primacy of the context of work over the content of tasks, and our fatally flawed approach to disability determination. Again, my hope is that reason will prevail over the vast establishment vested in the status quo so that someday the plight of the worker with a back “injury” will evoke empathic treatment and not approaches that predispose to persistent suffering and disability. That will not happen until we all understand why a particular worker might find a predicament of normal life, a regional backache, to be disabling. These chapters, more than any others, are a product of my own research over the past thirty years 2,3.
I have written extensively on the contemporary notion of “well being”4,5 and the fashion in which that social construction promotes the provision of irrational health care.6 Today’s backache is an object lesson. The implications for health care reform are also clear, and compelling.
Science has not arrived at contemporary understandings in a particularly straight-forward fashion. Hypotheses are never generated in a vacuum; they always carry the baggage of what came before. The more powerful stakeholders somehow find a way to impose their views and preconceptions. Research into back pain is a case in point. And back pain research is finally emerging into the light of reproducible results.
Metaphorically, one might imagine several enterprises vying to tunnel through a mountain of preconceptions about backache. Each staked out a unique starting point. Their progress is determined by the amount of backing they have and their paths rendered erratic by false-starts and unforeseen impediments. Each has its own sponsor with distinctive goals regarding prevention, causation, and treatment. Seldom do they share secrets. In fact, seldom do they take cognizance of each other as more than distant rumblings in adjacent passageways. Each excavation is leaving a mountain of detritus, the detritus of discarded hypotheses, at their tunnel entrance. This book compares and contrasts these tunnels to a degree that seldom occupies the excavators themselves. Most of these tunneling enterprises are now breaking through the crust of the other side of the mountain. The reader of Stabbed in the Back will be among the first to realize that they have come to a common egress.
Excerpted from Stabbed in the Back: Confronting Back Pain in an Overtreated Society by Nortin M. Hadler, M.D.
Copyright 2009 by the University of North Carolina Press
Used with permission from the publisher