The Rehabilitation of Persons with Low Back Pain (1993)

The population of individuals with disabling low back injuries constitutes a significant percentage of the caseloads of rehabilitation counselors working with injured workers, and thus requires an increased level of technical expertise on the part of the practitioner. Current research indicates that the phenomenon of low back disability is a highly complex problem and involves sociological, economic and psychological variables, in addition to the traditional medical model components. The current article reviews the many factors which can transform a low back injury into a low back disability. It assists the practitioner in becoming technically more knowledgeable with respect to back physiology and sociology, and offers specific principles to guide the practitioner during the rehabilitation process. Rehabilitation of the Person with Low Back Pain There has been an enormous growth of interest in disabling back pain in recent years. This interest has led to the involvement of medical, allied health and rehabilitation professions in its management, and has been responsible for the initiation of many new treatment strategies, therapy regimens and rehabilitation approaches designed to counter the increasing costs, both financial and personal, of disability associated with back conditions. The purpose of this article is to provide the rehabilitation counselor with a broad overview of the many and complex issues which will most likely affect the vocational planning process, and to provide a practical perspective from which to counsel clients on how best to return to gainful activity. Problem Definition Perhaps the most vexing issue in addressing the rehabilitation needs of an individual with complaints of back pain is how best to define the problem. Historically, the treatment of any condition involving significant pain symptomatology has been viewed exclusively as a medical problem. Thus in the case of persons with low back pain (LBP), a diagnosis is developed, (e.g., disc herniation at L4/5 with radiculopathy), treatment is rendered (e.g., surgical decompression at L4/5) and recovery is projected (e.g., 3-6 months for surgical recovery, physical therapy and return to work). However, in the case of LBP the medical model breaks down for two major reasons: 1) the vast majority of persons complaining of LBP do not require surgical intervention (McCorwin et al., 1991), and 2) the majority of persons with clear patho-physiologic abnormalities do not achieve complete pain resolution even after surgical intervention (Frymoyer & Cats-Baril, 1991). Consequently, the problem of LBP has become increasingly frustrating for physicians, since the prospects of a cure for this condition have proven to be exceedingly slim (Mayer & Gatchel, 1988). Re-defining the Back Problem Chronic back pain is the summation of physical lesions, lifestyle (esp. lack of exercise, diet etc.),age, hereditary factors, secondary gain incentives and psychological needs. AR must be addressed in determining both treatment plans and rehabilitation goals. Acute back pain may be the result of an injury to the muscles, ligaments, fascia and/or disc or its coverings, i.e. capsule. It is important to identify a probable medical cause but at the same time remember that a disc bulge seen on a CT or MRI scan does not necessarily suggest an acute injury. A bulging disc may very well have been pre-existent - and non-symptomatic - and may be the result of normal aging processes. Weisel et al. (1984), perform blind study in which 52 CT scans of persons with no history of back trouble were evaluated by three different neuroradiologists. They found that over 35% of these asymptomatic CT scans were interpreted as abnormal, with the most likely diagnoses being herniated nucleus pulposus (i.e., disc herniation), followed by facet degeneration (i.e., arthritis of the bony joints adjacent to discs) and spinal stenosis (i. …