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When compiling the second edition of the taxonomy of pain,1 the taxonomy
subcommittee of the International Association for the Study of Pain
(IASP) wrestled with the diagnosis of spinal pain. It recognised that
many diagnostic labels were illegitimate, inappropriate, or
fanciful. Nevertheless, it allowed certain labels drawn from the
osteopathic, physical medicine, and mainstream literature. In
doing so, however, the subcommittee stipulated strict criteria that
had to be satisfied if a particular diagnostic label was to be used. The
purpose of doing so was to ensure consistent, disciplined and
accountable use of terms. However, in many instances, the criteria
were such that they could not be satisfied using history and
examination alone, or even conventional investigations. The
purpose of setting such stringent criteria was to highlight the
deficiencies of contemporary practice and to indicate the need for
research into the reliability and validity of traditional
diagnostic practices.
In effect, the exercise established that it was essentially
impossible to render any conventional or traditional diagnosis for
low back pain. The means to do so were simply not available, not
reliable, or not valid. Consequently, the subcommittee argued that
the only intellectually and clinically honest diagnosis for most
cases of low back pain was "lumbar spinal pain of unknown or uncertain
origin".1 This rubric serves well
enough for purposes of classification and coding, but it is
cumbersome and unappealing for everyday use. Despite its accuracy
and honesty, the term is long and conveys the sense that the doctor does
not know what is going on.
Against this background it is not surprising that general
practitioners lack a decent vocabulary for labelling a patient's
back pain. The study of Schönstein and Kenny,2 of this
issue of the Journal, highlights the implicit difficulties that GPs
have in this regard when completing workers compensation
certificates. Their sample showed considerable variation in the
terms used. Yet, we cannot blame GPs; they are doing as best they can in
the absence of a satisfying, official term. Nevertheless, the study
reveals the need for standardisation.
Diagnostic labels are important in the management of patients.
Patients expect a name for their condition. A label shows that the
doctor knows what is wrong. But such labels should not be incorrect or
specious, lest they lead to therapeutic misadventure.
Zygapophysial joint pain and discogenic pain can not be diagnosed
clinically3,4 and are, at best,
suppositions. Other labels, such as "segmental dysfunction", are
only metaphors, with no established biological correlates. Some
labels are simply wrong and can have deleterious effects.
"Degenerative disc disease" conveys to patients that they are
disintegrating, which they are not. Moreover, disc degeneration,
spondylosis and spinal ostoearthrosis correlate poorly with pain
and may be totally asymptomatic.5 They are age changes and do
not constitute diagnoses. For this reason they were not admitted by
the IASP.2 "Nominated treating
doctors", in recording a diagnosis for back and neck pain, can at least
approach standardisation by avoiding these presumptive and
specious labels.
"Sprain" or "strain" are inferences about what caused the back pain,
but are based on what the patient reports. They can not be proven
clinically and therefore may or may not be correct inferences.
Nevertheless, these labels convey the notion that the pain and its
cause are not serious. This is the issue that Schönstein and Kenny
raise.2 Because it is not possible to
render a pathoanatomical diagnosis of back pain, it becomes
imperative to distinguish serious from non-serious conditions. In
this regard, it has become conventional to refer to serious
conditions as "red flag" conditions, the red flags being aspects of
history or examination that should warn doctors of the possibility of
a tumour or infection being the cause of pain. Mercifully, these
conditions are rare. Another term that has emerged is "yellow flags".
This pertains to certain beliefs, attitudes and responses that
patients may have to their pain that are counterproductive to
recovery. They include believing that activity will make their
condition worse, blaming work for their pain, avoiding social
activity, and relying on passive therapy.6 These are psychosocial
features that are unrelated to the cause of pain, and can occur even
with simple causes of pain; but they require attention lest they
impede, retard or prevent recovery.
What is lacking, however, is a term for back pain that is not associated
with red flags or yellow flags. Such a term should be more than
taxonomically correct. It should positively reassure patients that
they can confidently resume normal activities, without developing
fears or inappropriate behaviours. It is such a term that Schönstein
and Kenny are looking for.2 In the context of workers
compensation certificates such a term would provide more than a
convenient label. It would indicate a favourable prognosis and
convert the certificate from a disconcerting or confusing document
to a propitious and enabling one.
The terms "simple back pain" or "uncomplicated back pain" lack these
latter properties. The challenge remains to help Schönstein and
Kenny, and others, find a new term: one that is palatable to doctors,
satisfying to patients, and which not only means that there is nothing
seriously wrong, but also conveys the message that the patient has no
grounds for fear, and can expect recovery with straightforward, even
minimal, management.
Nikolai Bogduk
Newcastle Bone and Joint Institute
University of Newcastle, Royal
Newcastle Hospital, Newcastle, NSW
mgillamATmail.newcastle.edu.au
- Merskey H, Bogduk N, editors. Classification of chronic pain.
Descriptions of chronic pain syndromes and definitions of pain
terms, 2nd edition. Seattle: IASP Press, 1994.
-
Schönstein E, Kenny DT. Diagnoses and treatment recommendations
on workers compensation medical certificates. Med J Aust
2000; 173: 419-422.
-
Torgerson WR, Dotter WE. Comparative roentgenographic study of
the asymptomatic and symptomatic lumbar spine. J Bone Joint Surg
Am 1976; 58: 850-853.
-
Schwarzer AC, Aprill CN, Derby R, et al. The prevalence and clinical
features of internal disc disruption in patients with chronic low
back pain. Spine 1995; 20: 1878-1883.
-
Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of
patients with pain stemming from the lumbar zygapophysial joints. Is
the lumbar facet syndrome a clinical entity? Spine 1994; 19:
1132-1137.
-
Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial
yellow flags in acute low back pain: risk factors for long-term
disability and work loss. Wellington, NZ: Accident Rehabilitation
and Compensation Insurance Corporation of New Zealand and the
National Health Committee.
©MJA 2000
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