Back Pain In The Past
We can be pretty sure that back pain has been around forever. In consideration to our 4 legged biological past it is worth noting that dogs and horses are both known to present with symptoms of back pain that respond well to the same kind of care humans benefit from. So it seems fairly certain that back pain has always been a thing for we n8 humans and our ancestors. You’d have a hard time proving it, but I think it is safe to assume we have probably suffered with an increase of back pain recently, since we decided to opt for 2 legs instead of one.
The act of standing upright turned the lower spine into a fully weight bearing structure for the first time in our evolutionary timeline. It would be hard to overstate what a radical change this was for the lower spine. And yet we made the adaptation without adding any new ‘equipment’. We use essentially the same old set of bones, muscles and ligaments to stand upright as we did for 50 million years on all fours.
Modern humans are extremely prone to developing osteoarthritis in our spines, in many ways it is no more unusual than our hair turning grey. We also know from plentiful archeological evidence that our ancestors also suffered with ostoarthritis in their spines. When many Egyptian mummies were first medically examined, doctors mistakenly thought they had spinal diseases, when in reality what they were seeing was standard wear and tear.
Arthritis is extremely common to that point of being a normal finding past the age of 60, and yet where we develop it in our bodies tells a story of the way we move. It’s worth bearing in mind that, as we will see later in this article, the connections between osteoarthritis and back pain are not simple. There is no question however that osteoarthritis in the lumbar and sacral regions is circumstantial evidence for strain in our lower spines.
We don’t know how long back pain has been around, or how much back pain people had thousands of years ago, we probably never will. We know it wasn’t of particular interest to many medical scribes but that could simple be because they had bigger fish to fry in the form of mass disease and hunger. As we will see later in the article however, we know for sure that there has been a sharp increase in the number of people being disabled by back pain in the past century.
Based on what little we do known it is safest to assume that the story of back pain and it’s treatment is inseparable from the story of bonesetters. Bonesetters were lay people with inherited skills in managing pain and injuries. Skills usually passed down through families, no different to bakers and blacksmiths.
For thousands of years before the first self proclaimed medical doctors, orthopedists, chiropractors, physiotherapists, osteopaths and surgeons came along, bonesetters were where you went if you had pain. Bonesetters did (and still do in many regions) take responsibility for treating all serious muskuloskeletal pain and injuries. It is well known, and well documented that spinal manipulation has been practised across numerous cultures and often in including Indonesia, Hawaii, India, United Kingdom, Japan, China and India, by the shamans of Central Asia, Mexico, Nepal, Russia and Norway. To this day bonesetters and practitioners of spinal manipulation are estimated to provide 60% of significant pain and injury issues are treated in India.
The oldest confirmed human record of back pain treatment that we have is a document written in the upper Nile Delta 3500 years ago. The document clearly described a patient consult and treatment of a gentleman complaining of lower back pain. He is being treated by a lay bonesetter, what we would recognise today as a form of physical therapist This breadcrumb of evidence for the existence of back pain and it’s treatment both being old as the hills offers us a glimpse into a past most likely much longer the 3500 years.
The earliest Chinese text that mentions the use of needles dates around 90BC, It’s probably safe to assume they have been using needles for lower back pain treatment for quite a while. We are also told by scholars that’s there are many references to back pain as a recognised symptom in Ancient Greek and Roman texts.
It is very hard to know what sort of success rate all these practitioners had with the treatment of back pain, or indeed what their theories were about pain in general. There are modern studies into the art of bonesetting that have highlighted its likely value in remote and economically challenged regions.
Spinal manipulation is now widely considered a valid treatment for back pain, and of course manual procedures to relocate dislocate joints and the like are performed manually (as opposed to surgically) by the medical profession to this day. These observations are circumstantial evidence for the likely usefulness of the bonesetters toolkit. Conversely given their lack of understanding in anatomical and medical principles working with bone setters would have carried inherent risks
In terms of what we thought back pain was in the past there is some evidence for historical beliefs around back pain coming from forces outside of the body, and also many indications that back pain was frequently ignored or considered a symptom of something else all together. The retrospective good news for the patients of ancient healers is that the body doesn’t care if you think needles or manipulation let evil spirits out .. if a method works for back pain it works regardless of it being justified by superstition.
Rheumatism, Cold & The Spine
By the 16-1700’s, our position on the topic of back pain becomes far more clear. The concept of rheumatism was a significant part of medical theory at that time, and back pain was considered to be a form of rheumatism. The cause of back pain and of all rheumatism was considered to be exposure to cold and damp. Treatment by 16th century doctors largely centred around blood letting, primitive medicines in the form of tinctures and preferring examination of patients poo over examining the body.
It wasn’t until the 1800’s that concepts of back pain became more similar and recogniseable to us and how we think about back pain today. The idea that back pain was a condition unto itself arose at this time. It is during the 1800’s that concepts like ‘build ups inflammation’ and ‘irritation triggered by movement’ arose, while cold and damp were still largely implicated as causes. Treatments for back pain even became slightly more recognisable as they included cupping Perhaps most significant to our current understanding is the fact that in the 19th C the notion that the spine was the cause of back pain arose. It was also at this time that the idea of trauma causing back pain came quietly into being. These ideas about back pain prevail strongly to this day.
Orthopedics And Bed Rest
By the latter part of the 1800’s Orthopedists started to become the thought leaders on back pain and it’s treatment. Strictly speaking their area of expertise was deformities and arthritis, but they developed broader interests on the topic of pain including back pain. The concept of rest as a treatment arose at this time and became hugely popular as a result of the influence of orthopaedics .
There is a key moment in the latter 1800’s where a man called Hugh Owen Thomas who is now considered the forefather of modern orthopaedics made a decision that would lead to a healthcare disaster that has continued to unravel until this very day. Thomas was a descended from a long line of Welsh bone setters (people who used physical therapies and mobilisation to treat pain). Having studied as a bone setter and a medical orthopedist, Thomas made the decision to take parts of what he had learned as a bone setter but to turn his back on the idea of ‘mobilisation’ in favour of ‘rest’ as a philosophy on back pain treatment.
Unfortunately for what ever reason (it’s usually a man’s charisma in these instances) Thomas’s influence shaped the modern orthopaedic approach to back pain, one which we now know to have been tragically flawed. The concept of bedrest ultimately expanded from bracing and bedrest out to spinal fusion surgery as the idea merged with the rest of orthodox toolkit. Modern orthopaedic researchers now cite this transition as a disaster in the history of our species management of back pain. You may have noticed in our age that the widespread prescription of bedrest and spinal fusions for back pain has thankfully trailed off.
The next major step ‘forward’ in our treatment and diagnosis of back pain came in the early years of the 1900’s and was informed by the invention of X Rays. X Rays enabled us for the first time to peer at the spine of a living human and naturally became the investigation of choice in cases of back pain. From the get go there was an irresistible urge to explain a patients pain in terms of whatever appeared on the X Ray. A spectrum of ‘disease model’ explanations for back pain emerged and were matched with a roguish list of surgical procedures to remove and fuse certain spinal elements. Virtually all these procedures we now know to be useless at best, downright dangerous at worst.
To this very day countless people are told that the signs of osteoarthritis on their X Ray are the cause of their back pain, on the strength of the X Ray evidence alone. This trend can only really be understood with the benefit of hindsight, as we now know that the relationship between chronic back pain and spinal ostoarthritis is highly complex, in many cases quite ‘murky’ and in many cases highly tenuous. Even far more modern MRI scans struggle to accurately diagnose the causes of back pain
One thing is for sure for sure, there are countless people living today with spinal osteoarthritis and no chronic back pain, they prove that x Rays may be useful as part of a diagnostic process for back pain only.
Diagnosing Intervertebral Discs
At around the same time that X Rays became a fashionable component of back pain diagnostics, the intervertebral disc rose to prominence in the medical discussion about back pain. A handful of surgical cases under treatment for sciatica were recorded as being related to ‘disc tumors’. Given a bit of time and further investigation it became clear that these ‘tumors’ were in fact normal healthy disc material that had protruded. In addition it was spuriously surmised that this must be caused by an injury despite clear evidence to the contrary… to this day many still believe this myth due partly to the sudden onset of symptoms that is typical of disc protrusions. Nearly 100 years later the concept of disc injury looms large in the minds of patients and practitioners alike.
In terms of research we now know that while disc injuries can be a cause of back pain it is far less common than has been suggested . In fact for the most part, the diagnosis of disc related pain is generally considered in a tiny minority of back pain cases.
There is no question that our developing an awareness of the discs role withing the subject of back pain was an important step forward in understanding. Sadly though, the story of understanding disc related pain is inseparable from the story of human agony that has been the surgical intrusion into the topic of back pain. We now know that the disc is only relevant to a small number of back pain cases.
A further mess born of this newfound awareness of disc protrusions has been a 100 year long mass over-prescription of risky disc surgery procedures. Many surgeons in the front line began diagnosing all back pain and disc injury. By the mid 1950’s an awakened sub-set of orthopedic specialist began to speak out, one claiming that disc surgery ‘had left more tragic human wreckage in its wake than any other surgical procedure in history’. And the rest is history. Spinal surgeries that have now declined dramatically, and are now only even considered in cases of severe sciatic pain. In this new heavily moderated guise surgery is now helpful to those with serious disc related pain that doesnt respond to non-invasive interventions.
The trend of medicine has at this stage firmly swayed towards the view that ‘back pain is a disease that needed to be cut out or fused’. It is worth noting at this stage that on a professional level what we have seen is surgeons and orthopedists rise to assume significant political power, having previously been unregulated healing ‘sects’ not unlike the bonesetters themselves.
Throughout these years of escalating confusion over safe and healthy care options and increasing disastrous surgical invasion into the public’s spinal tissues the lay bonesetters have been marginalised and proclaimed as unscientific quacks. While actual bonesetters and the like continued to operate for better or worse.
The shift towards rest and surgery were unequivocally a commercial/political shift of power and not a scientific shift. To understand this fully it must be born in mind that discovering physical pathologies that sometimes relate to pain is not the same as coming up with a safe and scientific solutions to a problem. In the latter medicine was singularly failing at this stage. Bed rest and surgery feature nowhere on modern evidence based guidelines for managing back pain without severe leg pain, as it is now known that far from helping it is quite normal for them to make patients far worse.
It should go without saying that during the latter part of the 1900’s the use of pharmaceuticals as treatment for back pain exploded in popularity. In the earlier part of the century medical practitioners engaged with some forms of physical interventions like traction and of course bedrest, this ceased as the trend for the use of pharmaceuticals for just about everything that ails us including back pain. In yet another widespread piece of collectively careless and ill advised policy the over-prescription of pain killers for back pain has left yet more human mess in its wake.
The question of whether any of this is surprising should and could arise in the minds of those who view the topic of back pain with a degree of clear headedness. We have already at this stage understood back pain to be an issue with the structures of movement within the body, its essence is a biomechanical phenomena. To attempt fixing a fundamentally ‘mechanical‘ issue using ‘chemistry’ is logic on par with calling an electrician for a burst pipe. Luckily however pharmaceuticals are not the only back pain treatment narrative that gathered momentum during the latter part of the 1900’s.
The Back Pain Revolution
During the latter part of the 20th century there was finally an explosion of legitimate research into back pain which has thankfully been beautifully crystallised by the likes of the great man Gordon Waddell.
This vast interdisciplinary effort has been informed by principles from wide ranging fields including orthopaedics,neurology, physiotherapy, chiropractic, osteopathy, psychology and even sociology. The outcome is a far greater awareness of the factors that lead to bad cases of back pain and to some degree far more clarity on how to manage back pain by safe, non-toxic & non-invasive means.
This tidal surge of quality research has been undertaken by an army of conscientious researchers from numerous disciplines and has lead to the adoption of international guidelines for clinicians on how to manage patients with back pain. It’s hallmarks are a move away from surgical interventions, away from bedrest, away from the use of x Ray and MRI as standard diagnostic procedures and away from framing back pain as a ‘disease state’ and away from the reckless use of drug therapies .
Instead we are moving towards the judicious short term use of pharmaceuticals, toward manual and manipulation therapies like osteopathy and chiropractic, towards acknowledging the impact of emotional health in chronic pain and perhaps best of all toward exercise and movement. Some of what we have learned is genuinely new and revelatory, and some of it is what a legitimately skilled bone setter or yoga practitioner could have told you over 2 centuries previous.
One of the challenges we now face with research into useful non-invasive treatments like exercise and manipulative therapies is that most if not all of them under-perform in reductionist isolation of treatment, and complete non-isolation of nuanced back pain syndromes. Another issue is standardisation of treatment approaches. The randomised control trial is an extremely clumsy sword to yield in these realms. It presumes that all back pain is the exact same condition and all methods with the same name are the same treatment.. when they are in fact not
Unfortunately for the modern evidence paradigm effective treatment and diagnosis of back pain is a multi-factorial and nuanced. By way of example, f you arbitrarily test ventolin for its ability to relieve coughing fits it will perform very poorly, this is because not all coughing fits are asthma. You are testing ventolin against a spectrum of disorders many of which it is not ‘qualified’ to treat. ‘Non-specific low back pain’ is a symptom that relates to a spectrum of blended biomechanical and psychosocial disorders, therefore any truly valid data needs first to make these subtle distinctions.. which none have to my knowledge.
The Biopsychosocial Model
The biopsychosocial model of back pain is our current and cutting edge model for understanding not only back pain but the chronic disability that all too often arises from back pain. As you will see the biopsychosocial model offers a far more integrated and holistic perspective on back pain than we have seen up to this point. The word biopsychosocial is basically and 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.
Unlike the many preceding theories and models we have covered in the history of back pain treatment, 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 pain that we have yet to digest and widely disseminate as a culture.
You probably don’t know anyone who hasn’t heard of ‘core muscles’ and has at least a vague sense that they are relevant to the topic of back pain. This widespread awareness of the importance and relevance of muscle activity in preventing back pain is the fruit of recent developments in our understanding of factors that predispose us to suffering with back pain.
While there is still a great deal of progress required before we can honestly say that we are managing to successfully ‘scale’ these learnings but we know from a mass of data that exercise is a crucial factor in managing chronic low back pain. Quite a contrast to the dark days of bedrest. It is worth noting that to this day it is pretty clear you can’t exercise your way out of acute episodes of back pain, while keeping moving as much as possible remains king.
The Rise Of The Bonesetters
Moving into the 21st Century the triplet professions of Osteopathy, Chiropractic and Physiotherapy are positioned as fully fledged, regulated healthcare professions providing a substantial proportion of the care for back pain across the developed world. They have shaken off all the attempts to stigmatise them as unscientific quacks and are fully emancipated in the eyes off all but the most stubbornly ignorant. Their education standards are the lever by which they have elevated themselves to respectability. From one perspective (mine) the success of these professions represents in many ways the long overdue maturation of the tradition of bone setting.
Treatments like spinal manipulation, one of the mainstay methods used by physiotherapists, osteopaths & chiropractors are gaining a respectability of their own. As are treatments like acupuncture . Increasingly these treatments are making it onto worldwide interdisciplinary back pain management recommendations.
We don’t usually make the connection between osteopaths, chiropractors, physiotherapy and bonesetters. If we take a birds eye view of the history of back pain however, these professions arguable emerge as modern incarnations of these traditional healers. And so just like the surgeons, rheumatologists and orthopedists once did, they have elevated themselves through vital steps of regulation and education.
We live in a culture that worships technology, pharmacology and surgery are both seductive forms of technology. Both pharmacology and surgery promise convenient, rapid and simplistic relief to both patient and practitioner.
We are in love with technology for good reason, consider what it has done for our ability to travel in the past 200 years, we have moved from horseback to supersonic jets and everything in between. And yet technology is a sword with 2 very distinct edges. Look what technology and innovation has done to food preparation and food manufacture in 200 years. We have moved from broccoli to mechanically separated chicken and hydrogenated vegetable fats with dire consequences not only for ourselves but also the planet.
It may be that some areas in life are left relatively untouched by technology?!
My personal reflection as someone who has helped thousands of people out of chronic and re-occurring cases of back pain is that a broad, open minded and minimally invasive approach performs extremely well. This approach benefits from modern research findings on the nature of back pain, it benefits from certain pieces of modern technology and it benefits from the use of methods and insights that have been working in a safe non-invasive manner for thousand of years. It is a willingness to combine and integrate known elements that brings success, over and above adherence to rigid thinking and approaches.
With respect to all the crazy notions and treatments we have entertained about back pain down the ages. Many of beliefs still held by the public and even many practitioners in our present day continue to be a far cry from the reality of what we now know about back pain. If you take to the streets and ask 100 people what they think you should do about your toothache you will receive an extremely consistent and to be honest pretty expert opinion for the most part. We know what causes dental decay, we know how to prevent it and we know exactly what to do if we fail. In contrast if you ask 100 people to advise you on your back pain you will receive a wildly disparate spectrum of answers, and it’s highly unlikely that any of it will relate to an awareness of the biosyphosocial model of pain. This observation points to what may be our biggest challenge in moving forward with back pain…. education.