Aum Pema (name changed), a businesswoman in her late fifties, hurt her back while lifting some items fifteen years ago and had suffered low back pain since. Though she didn’t give much attention to it, the pain persisted and gradually spread down her right leg. When eventually she went to a doctor, the MRI showed a rupture of the disk below the fourth lumbar vertebrae.

Story such as this is the proverbial tip of the iceberg. Low back pain is indeed the cough and cold of the lower back; it’s something most people experience at least once in their life. It’s a global epidemic affecting at least 1 in 13 people in 2020 alone, as well as a leading cause of disability. Though it is often a temporary condition, yet, low back pain becomes disabling and distressing for many, negatively impacting their daily activities and the quality of life.

Causes of low back pain

Only 1 – 2 percent of low back pain is caused by serious pathology like cancer, infections, systemic inflammatory diseases and fractures. Such conditions require urgent and appropriate medical care. Another 5 – 10 percent of low back pain are due to specific and identifiable anatomical structures resulting in neurological deficits – weakness, loss of sensation and voiding dysfunction – requiring imaging and surgical treatment.

However, about 90 percent of low back pain are non-specific, meaning, there is no identifiable tissue to adequately account for the pain people feel. Such a pain often results from complex interaction between psychological, distress, pain response, behavioral, beliefs, social, genetic, physical, lifestyle and other health factors. Just as fingerprints are unique for individuals, the contributions of these factors in causing pain are unique among different people.

Doctor shopping

Aum Pema visited me five years ago. In the last 10 years, her pain had spread all over her back and legs, forcing her to shuttle from local healers to physiotherapists to masseuses to surgeons not just in Bhutan but also in India and Bangkok, depleting her resources in the process. This hopping from doctor to doctor in hope of getting better is called doctor shopping. When she finally came to me, her hopes were roundly dashed. And yet, she wanted to give it a go as she had seen me on the national television talking about patient care.

How people seek healthcare is influenced by a number of factors. In rural communities, people seek help from the shamans, bone setters, or rely on herbs and ointments. Some “wait and see” and knock at the hospital’s door only when they can no longer take the pain. Their urban counterparts get over-the-counter medicines from pharmacy shops. Some do visit a hospital where the common options available to them are painkillers, physiotherapy, and traditional medicine. In some cases, back surgeries and steroid injections are involved, if the common management options fail to alleviate the pain.

A study concluded the care for chronic musculoskeletal pain in Bhutan is inadequate as healthcare professionals focus on identifying defective tissue to pin the blame for the pain on such tissues. This lack has its roots in university training where chronic back pain is given a pass as non-life threatening and unworthy of much medical attention and resources.

If a patient receives inadequate treatments, he/she tries everything they can, hop places and professionals. When all recourse fails, the vicious cycle of trying everything begins, often interminably. Frustrated and distressed by conflicting health information, they fall victim to quacks and charlatans who milk their vulnerability, selling ersatz treatments based on bogus pseudoscience that are not just ineffective but also harmful.

Paradigm shift

Experts call for person-centered care for low back pain. Traditional doctor-imposed care of low back pain has largely failed as evidenced by the growing global burden of disabling low back pain, disproportionately affecting the developing countries already overloaded with infectious and non-communicable diseases, among other public health priorities.

Person-centered care takes into account a person’s culture, knowledge, value systems, preferences and goals in making treatment decisions and managing pain. In other words, communication between a doctor and patients becomes two-way, with patients having a say in their treatment and what works best for them. It’s about identifying modifiable and non-modifiable factors contributing to the pain experience and shared-decision making to arrive at the management plan together.

Patients often request radiological imaging or, simply, photographing the inside of the human body with the help of high energy beams. Experts don’t support this unless a serious and specific disease is suspected. Injudicious use of imaging is not just unhelpful; it can be harmful. For example, sensitive imaging like MRI captures normal physical changes in the body related to aging that do not cause pain but get interpreted as the cause of pain. Such misattribution can lead to medicalising benign age-related physical changes, resulting in avoidable worry and stress — or even unnecessary invasive treatments.

Musculoskeletal conditions do not receive sufficient attention in developing countries, and Bhutan is no exception.  We need to invest in epidemiological studies, assess the healthcare cost incurred in low back pain, economic implications (medical leave, early retirement, etc.) and negative impact on quality of life. Reliable data helps in providing appropriate care, planning human resources in healthcare and delivering public health messages. We need to translate the clinical guidelines of international standards to our socio-economic and cultural context.        

Role of Physiotherapy 

Physiotherapy often gets mistaken for massage and passive treatment options. Aum Pema expected the same from me – massage; though she already knew massage would not help her.

I had to take her through a personal journey of recovery. After thorough assessment, I entrusted her to steer her treatment. We picked on key contributors to her pain, her values and designed a person-centered care plan. She maintained a pain diary and the trajectory wasn’t simply linear in which pain gradually slopes down but spikes of ups and downs, highs and lows, hopes and despair. I only observed the progress. She detested being the driver but she knew she wouldn’t reach her destination without driving it herself. She followed up weekly for months. Once she gained confidence with the self-management strategies, she discontinued hospital visits. Three years later, Aum Pema claimed that she got back her life.

8th September is annually observed as World Physiotherapy Day. Every year a theme is highlighted. For 2024, it is low back pain. It’s a day to celebrate the success of past years, reflect on what could be better and reaffirm our responsibility to provide holistic, evidence-based, sustainable and person-centered care. It is also the day we create awareness on different health conditions to provide knowledge grounded in evidence.

Evidence-based and psychologically-informed physiotherapy management of low back pain is an effective non-pharmacological intervention to move away from harmful healthcare options and minimize the burden of low back pain.

Contributed by

Monu Tamang

Physiotherapist

Central Regional Referral Hospital, Gelephu