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Back pain: coping versus treating

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years (see updates page).

From a 1998 paper by Hadler and Carey, “Low back pain: an intermittent and remittent predicament of life”:

The tragedy of the past 50 years of the approach to the management of back pain in advanced countries is that we’re treating the wrong illness. We hear the patient complain of back pain when we should be hearing the patient proclaim, ‘My back hurts, but I’m here because I can’t cope with this episode.’ If we could learn to listen to this chief complaint, perhaps we can tackle the impairment in coping, which is the illness that renders the predicament of back pain intolerable.

Is that really what the patient is proclaiming? I have a love/hate relationship with this statement. On the one hand, back pain is largely untreatable, and there’s a lot to be said for focussing on the more achievable goal of better coping. “Just give me the good stuff, doc!” Whatever that is. It’s obviously not opioids anymore.

But I’ve seen many people legitimately cured of back pain: diagnosed and treated competently, with a genuinely happy ending. I have seen too many stories like that to be comfortable framing the desperate pleas of patients as a request for help merely “coping.” Why not both? I am sure that, in addition to coping, patients also want diagnosis and treatment — which is undoubtedly possible in many cases.

Perhaps the lack of widespread back pain expertise is a more serious problem than failing to “listen to this chief complaint.” We’re not “treating the wrong illness,” we’re treating it ineffectively, because we don’t understand it well enough yet: too many known unknowns and unknown unknowns. Too much of a tangle of factors in many if not most cases.

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