Backs in the Future: A Journey Through the Spinal Landscape
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EDITORIAL
Backs in the Future: A Journey Through the Spinal Landscape Chris J. Main1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction The purpose of this article is to offer a personal perspective on my involvement with the assessment and management of low back pain (LBP) over four + decades as both a clinician and a researcher. The story begins with a biomedical (orthopaedic) perspective on which is built the psychosocial components leading to the development of the biopsychosocial model of LBP; moves to the establishment of a tertiary pain management programme and the development of secondary prevention; and concludes with the description of psychologically informed practice (PiP) as a way of establishing guided self-management. On the journey, consideration will be given to the development of assessment, screening and targeting treatment in both clinical and occupational settings. It concludes with reflections at the levels of individual management, organisations and health\social policy. I have struggled with a number of questions over the years, which can serve as a road-map of the “drivers” underpinning the LBP story. I began in the orthopedic world with a number of questions about LBP, such as:
Why do People with “Apparently” the Same Physical Findings Differ in how Disabled They Become? Answering that question proved extraordinarily difficult since the measurement tools available to measure LBP and its effects were poorly constructed and inadequately validated. We had to construct our own.
Can we Explain Pain‑Associated Disability in Terms of Psychological Factors? Psychologists, steeped in psychopathology, purported to explain differences in symptom development from
“psycho-anatomical X-rays” using cumbersome psychometric tests such as the Minnesota Multiphasic Personality Inventory (MMPI), which contained virtually no questions about pain or pain coping strategies. We set about assessing the relationship of a range of tests with pain and level of disability and we found that fairly simple assessments of somatic awareness, depressive symptoms and behavioral signs and symptoms explained a significant amount of variance in disability, even after controlling for physical findings. This enabled the construction of the Glasgow Illness Model [1]. (A specific focus on the assessment of cognitive factors in pain had not yet been developed).
Can Health Care Providers do Anything to Help People with High Levels of Chronic Pain and Disability? We established an inter-disciplinary pain management programme in Salford, allowing us also to explore some of the psychophysiological features of LBP and the role of fear [2] for which we developed the Fear Avoidance Beliefs Questionnaire (FABQ) [3]. We also developed a brief occupationally focussed approach for treating unemployed LBP sufferers in receipt of time loss benefits [4].
Can we Identify People Likely to Develop Chronic Pain and “Unnecessary” Levels of Pain‑Associated Distress and Disability? As an evidence-informed model of
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