In the early part of the 20th Century back pain was still often put down to ‘rheumatism’ and seldom explained in very clear biomechanical terms. With the invention of Word War quickly followed by ⅓ of the planets population dying from Spanish flu I think it safe to say we had other things on our mind.
The overarching story of back pain treatment during the 20th century underwent a transition from long standing traditional healing methods like Bonesetting to the modern medical model… and thankfully out the other side. There were also some intriguing subplots to the story we will look at.
We will have to give mainstream medicine a bit of a roasting, but it is all said with great respect for what medicine can do to help us in other areas. The person writing this blog would not be alive if it wasn’t for the skill and care of his doctors.
Medically Prescribed Bedrest
One of the first (and as it turns out most damaging) trends in back pain treatment during the 20th C was the recommendation of bedrest. This idea was propagated by the relative new kids on the block ‘orthopedists’, whom we now know as orthopedic surgeons. The notion of ‘healing rest’ to relieve irritation of the spinal tissues is admittedly one that looks good enough on paper. As it turns out though, if you have back pain lying flat on your back for 6 weeks leads to increased stiffness, muscle wasting and clinical signs of depression, all excellent ways to make back pain a lot worse. It would have been around this time that we started seeing an increasing number in more severe cases of back pain, as opposed to the milder episodic kind.
The second phase of medicines attempt at resolving back pain was characterised by surgical disc repair and spinal fusions. Spinal surgery was and is an attempt at treating back pain as if it is a ‘medical condition’ as opposed to a ‘biomechanical & wellbeing condition’. Diagnosing and explaining back pain through the many spinal abnormalities and imperfections so many of us have (most of which never cause pain) is and was a major misenterpretation of the 99.99999%. We now know that only a microscopic % of all back pain sufferers who qualify for surgery, and yet in the middle part of the 20th C it was used as a major form of treatment. All this is why so few people now receive surgery for back pain, research thankfully exposed surgery for what it was… a mistake.
**If you have a major disc prolapse and severe leg pain surgery can definitely be an excellent short term solution. Especially with modern procedures that have become less invasive.
The third phase of medical treatment for back pain in the 20th C was drug therapies. This is a fire that continues to rage out of control to this very day. Back pain in our society has form reasons that go beyond this specific article raged out of control since the end of WW2. Our drug of choice for dealing with this issue has been .. well .. drugs. Painkillers, Non-Steroidal Anti-Inflammatories, Steroidal Drugs and Opiods are all in the mix.
In the short term I don’t think anyone would argue with the value of a painkiller, sometimes we just need a break from being on pain. The issue with using pain medications to treat back pain is more in relation to their use in the longer term management of back pain. The cost of using drug therapies to manage your back pain in the mid to long term is twofold. The first issue is the inevitable physical toll that some of these drugs in particular have on the body. The second toll is that they often act as a distraction or substitute for legitimately scientific and accountable rehabilitation of back pain.
When it comes to the use of drug therapies it is hard not to wonder if medicine has opted for them as the last available tool in the box. With great respect for all medical practitioners and the good work they do it is a fact that their training does not extend to accountable and up to date pain management, except in a few rare cases where they have done extensive extra training. Family doctors are spread incredibly thin in terms of their scope of practice. Orthopaedic surgeons almost have the opposite problem in that they are hyper-specialised to diagnose and treat the minority of pains that require surgical attention. Neither of these positions are a great foundation for rehabilitating patients with stubborn back pain.
There have been 3 major sub-plots in this ‘back pain treatment in the 20th Century’ story that we have not touched on.
The word ‘chiropractic’ comes from the Greek words cheir (meaning ‘hand’) and praktos (meaning ‘done’), i.e. Done by Hand. The name was chosen by the founder of chiropractic, Daniel David Palmer. DD Palmer was a self taught healer. Pioneers often are by necessity self taught. Through his formative experiences Palmer had developed an interest in the relationship of the spine to health. He learned that various forms of spinal manipulation had been used by healers for thousands of years, but that there had never been a philosophical or scientific rationale to explain their effects. Palmer essentially developed a working hypothesis that was to become a major healing profession was based on his ability to reason and his extensive study of anatomy and physiology.
Palmer performed the very first ‘official’ chiropractic adjustment in September of 1895. From that first adjustment, DD Palmer continued to nurture chiropractic theory and practice and in 1897 established the Palmer College of Chiropractic, in Davenport, Iowa, where it remains today. The first state law licensing chiropractors was passed in 1913, and by 1931, 39 states had given chiropractors legal recognition.
Fast forward to today millions of people are treated by chiropractors all over the world each year and there are chiropractic colleges all over the world. Chiropractors have made a significant contribution to the field of pain management. Legislation across the developed world acknowledges chiropractors as primary healthcare providers thus having essentially the same legal standing as doctors and dentists.
Early theories around the influence of the chiropractic adjustment have inevitably over 100 years been found wanting and are under extensive revision by researchers. Irrespective of this spinal manipulation is now officially listed on virtually all scientifically validated international guidelines for the management of back pain. Traditional chiropractics’ contribution to the management of back pain is in some sense limited due to the complexity of what is required to manage a population with back pain. A modern european style chiropractic training however goes way beyond the scope of traditional chiropractic and encompasses a broad range of evidence based perspectives and techniques. Chiropractics’ contribution to the management of back pain since the beginning of the 20th C has been a far less bloody and toxic affair than that of medicine. It was never a competition but the comparison holds value for those of us seeking help with our pain.
Osteopathy was founded in the late 1800s by physician and surgeon Andrew Taylor Still in Kirksville, Missouri. The son of a surgeon, Still developed the belief that in order to achieve excellent health, all parts of the body should effectively work together in unison. His concept was the restoration of the body to optimum health with minimal surgery and medicine.
Over time Still experimented with treated patients with a wide range of conditions and gained a reputation as an effective practitioner. In time patients began to come from all over America to Kirksville for treatment. Soon demand was so high the very infrastructure of Kirksville needed to be altered to cater for the amount of people seeking treatment from Still.
In 1892, Still took on the first wave of 22 osteopathic students at the American School of Osteopathy (now known as the Kirksville College of Osteopathic Medicine). The first class of both men and women (symbolic of Still’s strong sense of liberalism) were taught over a period of two years, and included in-depth education in physiology and anatomy. He drew in full practice rights for his students, and upon graduation, awarded them the title of D.O (Doctors of Osteopathy).
The Osteopathic profession grew rapidly and by 1917 the British School of Osteopathy was being founded, this ladi what proved to be the strong foundations for osteopathy in Europe. Osteopathy experienced some mild moments of uneasy integration with medicine during the 20th C. Ultimately osteopathy did not become a legally regulated profession until the introduction of the Osteopaths Act in 1993, which led to the establishment of the General Osteopathic Council, as well as the Register opening, in 1998. Like chiropractic and professions, osteopathy is now subject to statutory regulations and qualified practitioners need to register with GOsC in order to practice and use the title of ‘osteopath’.
Like the chiropractors, osteopaths have made a valuable contribution to the non-invasive, non-toxic and consrvative treatment of back pain since their professional birth just over 100 years ago. Osteopaths are ideally placed as a profession to carry forward the torch of ‘best practice’ as more and more data emerges on how best we should collectively manage lower back pain as a society.
The Biopsychosocial Model – The Beginning Of A Happy Ending
The 20th C ended on a high point for our understanding of lower back pain. The early beginnings of all healthcare professions starting to work as a team were seeded, and we finally began the process of developing a consensus on what to do about back pain. We now have provisional inernational guidelines for managing lower back pain because there has finally been enough research for us to start to ‘put our feet on thw ground. One of the most important concepts to arise in the late 20th C was the biopsychocosial model of lower back pain developed by an orthopedic surgeon by the name of Gordon Waddell.
The biopsychosocial model of back pain is our current model for understanding back pain and the chronic disability that often arises from back pain. The biopsychosocial model of back pain offers a far more integrated and holistic perspective on back pain than we have had at any known previous point in history. The word biopsychosocial is an abbreviation of the words…
biological – relating to the bodies tissues,
psychological – relating to the mind
sociological – relating to society and culture.
The biopsychosocial model acknowledges that back pain and in fact all chronic pain is not only physical, it is profoundly influenced by emotional wellbeing, belief systems and the cultural way that we approach pain and those who suffer it. The biopsychosocial model is born of careful, considered and accountable science. It is likely not perfect and it will no doubt be amended, but it offers a quantum leap in our understanding of back pain.
The shocking rise of long term disability caused by back pain means that for may this conversation is really not about back pain treatment at all, it’s about freedom. Serious cases of back pain matter because they limit your freedom to enjoy the most basic parts of a happy, normal life. For some back pain means the inability to enjoy certain activities. For others back pain limits their ability to perform their duties of care to others and connect with the most important people in their lives. For those with the worst cases of back pain, relieving it means just being able to walk, stand, sit and sleep without pain… some of the most basic forms of freedom. These are the real facts behind the topic of back pain and the rest is just the details of how you get to these goals.