The Long View on Low Back Pain
A systems analysis of this condition opens doors to understanding why back pain persists, how it changes over time and how we can more effectively treat it.
Low back pain (LBP) rivals cardiovascular disease (CVD) and cancer in treatment expense in the Western world. While the mortality risk associated with low back pain pales in comparison to diseases like heart disease, diabetes, cancer and Alzheimer’s disease, the impact on one’s life (as measured by the public health term-Years Lived with Disability or YLD) is much greater with low back pain. Why then, are we still struggling to understand low back pain and to develop an effective way to reliably treat it?
The answer to that question is associated with a phenomenon that many have seen in other domains in the early part of the 21st century…it’s a complex problem which requires systems analysis to better understand. Here are a couple of examples of of some other systems based problems that you may have heard of:
- Climate change
- Effects of Covid on public health
The complexity of the variables associated with the above conditions, combined with the impact of social media on journalism and politics, means that the variety of views on these 2 examples can be wide ranging and sometimes in seeming opposites. Hey! That kinda’ sounds like a systems based problem too, doesn’t it! :)
Forgive me. For a simplified view of systems based thinking and application, here is a link to a solid article on Medium that may serve as a jumping off point. For our exploration, we can go back in your own mind to a place that many of you have some uncomfortable memories of…your junior high and high school math classes.
By that time in our education, many of us have graduated from the comfy linear logic of earlier arithmetic training of addition, subtraction, multiplication and division, and we start to move into that weirder world of (duh, duh, duhhh) algebra. Remember this old fave from Pythagoras?
a² + b² = c²
Or maybe those lovely distributive equations like,
[2(1+3)] + 2 =x
These algebraic type equations help to introduce some of the elements in a systems-based approach to low back pain.
PRINCIPLE 1: INTERCONNECTEDNESS
What I’m driving at here is the idea of interconnectedness, which is the most basic principle of systems based thinking. Put simply, if you change one variable, the entire output of the system is altered. Here’s another doozie of a challenge for normal people to get their heads around…
PRINCIPLE 2: EXPONENTIAL RESPONSE
Here we can use the common savings formula as an example. Take one penny and double it every day for 30 days. At the end of 30 days, how much do you have? Answer = $5,368,709.12. And here’s another place in the systems analysis world that humans struggle intuitively with,
PRINCIPLE 3: LATENT FEEDBACK
Where I am writing this, the room is cold. I go over to the thermostat which is in the next room and increase the temperature. How long will it take before I am comfy again? Well, that depends on…
- if I put on a sweater,
- if I partially close the door to the room I am writing in,
- what the BTU output of my furnace is,
- whether I have had the furnace serviced
- etc., etc., etc.
All of these things are variables in this example. Have I lost you yet? Wait, weren’t we talking about back pain? Yup.
The back pain of a 22 year old offensive lineman on the football team is not the same as the back pain of a 35 year old single mom, which is not the same back pain of a 65 year old retiree. That’s true even if all 3 of these people have sustained injury to the exact same structure. Other variables are at play. Many of those variables are specific to the individual and some can be generalized to the population.
Over the next several articles, I will attempt to examine some of the variables that are associated with low back pain in an attempt to develop a coordinated rubric for solving this problem. Like in the working of many systems based problems, we will use reductionism to examine the variables that have been identified in the scientific literature. Unlike many of the things you may have read about back pain, we will then examine those variables and how they compute in the algebra of back pain in the individual, by using a systems-based approach. It is my hope that this will help both the individual with back pain to find a way out of their misery and that it will help the confused clinician to wade through the most futilistic of clinical entities, “non-specific low back pain”. What is the value of this process? Well, in purely economic terms, some estimates suggest that treatment for low back pain may be as high as $600 billion (yes, that’s a B) problem in the U.S. alone, making it the 2nd most expensive item to treat in public health.
An overlooked, but very common concept in chronic back pain is the concept of how perceived threat can make back pain behave much like post traumatic stress syndrome (PTSD). Click on the link to learn more.