I was delighted to attend and represent BU at The Society for Back Pain Research (SBPR) Annual General Meeting 5-6 November 2015 which was conveniently held in Bournemouth, at Anglo-European College of Chiropractic, a partner college of BU. SBPR was formed in 1971 to promote the study of all clinical and scientific aspects of spinal pain, including the neck (my area of interest), and to encourage research into its causes, treatment and prevention. There are now over 200 members of the Society, from a wide range of disciplines including all sorts of healthcare professionals and scientists. Suffice to say if there is anything about back pain this audience does not know it is probably not worth knowing! Having said that, attending this meeting reminded me just how much about back pain is still unknown…
Biological Factors in Non-Specific Back Pain
The title of this year’s meeting was ‘Biological Factors in Non-Specific Back Pain’ to place an emphasis on the ‘biological’. It has been over 25 years since the biopsychosocial model was applied to back pain but lately research has tended to be more concerned with psychosocial aspects, such as fear-avoidance behaviour or depression; research into physical findings to diagnose back pain has sadly not been very fruitful. [An important point was made by Professor Maurits van Tulder, that research has actually been largely focused on psychological factors, to the expense of social factors]. While psychosocial factors do seem to be important in influencing patients’ recovery, they don’t get us much closer to a diagnosis, to finding out what is producing and driving the patient’s pain.
In terms of disability-adjusted life years (DALYs) (the sum of years of life lost due to premature mortality and years lived with disability) from non-communicable disease, low back pain ranks #3 (after ischaemic heart disease and stroke) and neck pain # 14 in the top 25 leading diseases and injuries globally. In the United States low back pain is the number one cause of years lived with disability. If you are not involved in the field of musculoskeletal disorders as a researcher or clinician, it may surprise you to know that, despite the size of this problem, it is still not possible to gain an accurate diagnosis for most back pain sufferers. X-rays tend not to give us useful information so guidelines recommend not using them in most cases. While MRIs provide more useful pictures than x-rays even they are not proving to be as useful in diagnosis as we would like them to be.
Future directions in back pain research?
However, one of the presentations at SBPR hinted at where the research focus as regards imaging (and MRI specifically) could perhaps go. One of Associate Professor Mark Hancock’s suggestions was that we need studies that focus on changes in MRI, in response to treatment (or no treatment). But how do we best measure such changes? (My own research into measuring changes from motion x-rays in response to treatment highlights these measurement challenges – new paper on changes to cervical lordosis after SMT will be published imminently). Which treatments and for whom? Could findings on MRI in a person without back pain predict back pain in the future?
Another presentation, by Dr Judith Meakin of the University of Exeter, provided some exciting insights into how the spine might be better understood using finite element modelling, which (if I interpreted correctly!) is a mathematical approach that aims to reduce the complexity of a system into more simple parts that are easier to understand and quantify. Put even more simply, this technique can be used to produce computerised 3-D models of a person’s spine. Forces can then be exerted on the computerised spine to find out where the spine structures are failing, and therefore contribute to a diagnosis.
‘Be careful of what you vote for’
The lack of knowledge concerning back pain is exemplified by the title to this meeting, ‘Biological Factors in Non-Specific Back Pain’ and the motion of the debate that closed the meeting: ‘Non-specific back pain is a valid concept’. I won’t go into the details but the “for” camp won by a small margin. I might give away which camp I am in when I say a diagnosis cannot be provided by such a label, it simply tells one what it is not i.e. not specific. Without a specific diagnosis we can only guess at what the correct management package is for any given patient and without it, it is hard to see how the global burden of back pain might best be challenged.
In image from left: Associate Professor Wim Dankaerts and Mr Nick Birch (Against); Mrs Elaine Buchanan and Professor Charles Greenough (For)
So, to sum up, the SBPR meeting provided more questions than answers, which is perhaps not untypical of such events. Will another 25 years of research bring us the answers we need?