Back Pain and the Sense of Coherence

A colleague of mine relayed a story of a new patient that just started to see him for Physical Therapy. This person had several accidents and a neck and shoulder surgery. He was in severe pain and any movement to the neck and shoulder would increase his pain. He had some not-so-good experiences with physical therapists and other practitioners in the past and had little hope of getting help at this time. He told my colleague that he thought that this was what his life was going to be like, full of pain and unable to do what he wanted to do in life. My colleague saw this person was wearing a religious symbol on a chain around his neck, and said to him "I see that you have some strong convictions about how you live your life, are you willing to let in a sense of hope and to work with this problem to try to make it better." Hope is an intangible factor in dealing with problems surrounding the alleviation of pain.

The factor of intangibles arose at a recent conference of the American Academy of Orthopaedic Manual Physical Therapists. The keynote speaker was Stefan Blomberg, MD, PhD from Uppsala, Sweden. He gave an excellent lecture on his dissertation research titled "A Pragmatic Approach to Low-Back Pain Including Manual Therapy and Steroid Injections, A Multi-center Study in Primary Health Care". In his research, 101 patients with acute or subacute Low Back Pain were randomly allocated to one of two treatment groups. One group was given standardized conventional treatment by primary health care teams. This included drugs, exercises, corsets, electrical stimulation or ultrasound and various other treatment modalities. The other group received manual treatment (by Physical Therapists) such an specific mobilization, specific muscle stretching, auto traction, manipulation, exercise and cortisone injections.

The two groups were similar for most of the pretrial variables. Although both groups improved with treatment, the group receiving specific manual treatment had significantly better outcome that the group receiving conventional treatment. They had less time out on sick leave, lower self-reported pain scores, lower consumption of medications, better lumbar movement, and a faster rate of recovery. Even two years later, Dr. Blomberg reported, the group that received the specific manual treatment was doing better that the other group. This is good news to not only help practitioners be more effective with treatment, but also to show insurance companies the importance of coverage of these services.

In addition to the well done efficacy studies, Dr. Blomberg went on to explore why back problems effect various people differently. We often speak of treating dysfunction (I will use the definition of dysfunction as being micro-pathology or disturbed function of anatomical structures that is reversible). This is different from patho-morphological problems in which there are major structural problems such as a herniated disc or bone spur. It is interesting to realize that there are now a few good published studies that show that there are a lot of people running around with arthritis, bone spurs and disc bulges, as shown on x-rays and Magnetic Resonance Imaging (MRI) tests that don't even know it. They don't have any pain or problems with their backs. So what is the difference? Why do some people with seemingly major back problems or dysfunction go along without the problems keeping them down for long, while other people with seemingly less severe problems or dysfunction are incapacitated by them.

Dr. Blomberg explored this puzzling question by referring to a book written by Aaron Antonowsky, Unravelling the Mystery of Health. In his book, the author develops the concept of a sense of coherence. He has a 29 item list of things that are involved in a sense of coherence. In short, a sense of coherence involves the intangible things such as being able to control ones life, and having a reason for being. The people that have this sense are able to accept a new condition (or problem) and continue to function. The people that have a limited sense of coherence are stuck in a reactionary response to life. Physical, psychological and social problems seem to push these people over the edge from function to dysfunction. This sense of coherence seems to be well formed by the ages of 20-25.

Dr. Blomberg stated that this book had made a great difference in his practice. He asserted that we must be able to find reliable predictors of prognosis for people with Low Back Pain. A low sense of coherence seems to be a risk factor that we must consider. I was heartened to see that Stefan Blomberg, who has done much good double-blind, objective research on effective treatment of people with back pain also sees the importance of considering the incorporeal in our lives. He asserts that we must continue to work within the scientific system and power structure to document the effectiveness of treatment and perhaps find a way to incorporate the examination of how these less tangible factors affect peoples health. Isn't this what mind-body medicine is about?

Written by Krista J. Clark, PT


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