Significant milestones in the research arena for back pain which I have
witnessed over forty five years and have in turn been relevant towards
developing my Primary Care services delivery: -
A new theory about pain mechanisms was published in 1965 by Ronald Melzack and Patrick Wall. Entitled the gate control theory of pain it created a profound change in the understanding of pain at that time. Inevitably our understanding has advanced considerably further but the essential elements of their theory initiated the pathway to where our understandingg is currently. [An event which still comes to my mind quite clearly is attending a workshop led by Pat Wall just months before he died of cancer in 2001.]
Late nineteen eighties - Professor Gordon Waddell introduced the early concepts of the Biopsychosocial Model and thereby began the idea of a health care model in primary care more comprehensive than that of the of the then current "biomechanical model" and "injury model". This offered the beginning of a more practical and pragmatic approach to the broad spectrum of back pain therapeutics for the individual..
Through the nineteen nineties, the work of Peter Croft and team establishing evidence to support the epidemiological understanding of back trouble being normal within society. For each of us, the pain expressed is our personal individual expression of trouble in the back.. Through this time also, the challenges and accumulation of "evidence"- based knowledge (of that time) facilitated a plethora of treatment guidelines from many countries - with each saying much the same thing.
Early 2000, saw the work of Kendall, Main and Linton leading to the concept of "obstacles to progress" of the then current treatment models and in the trade referred to as "Yellow Flag".patients. This new evidence when viewed in the context of the Biopsychosocial Model offered strategies to develop diagnostics and treatment to assist the more complex clinical presentations of back pain. It was realised that so often, prolonged periods of pain (months to years) reflected for the patient possible unresolved psychosocial problems which severely diminished that patent's ability to manage their pain and diminished the opportunity of satisfactory outcomes from much Primary care treatment used at that time.
And so through to date, with the revelation of human diversity created by the genome (and the functional concept of epigenetics) conspiring with the tsunami of knowledge arising from the neurosciences reflecting each person's unique life history from cradle to grave. While diversity rules, research of the last fifteen years has valued the opportunity of defining sub-group populations which offer answers to questions the proponents of large clinical trials from bygone times could never conceive in their own "hay-day".
Away from research and to the coalface of clinical delivery.
There are those patients with more complex longer term back trouble not suitable for surgery but who would gain value from coordinated clinical primary care therapeutics and perhaps, parallel pathways. This concept for back pain still has a very long journey to achieve and apart for being more sensitive for each patient’s needs, there is evidence that to keep the patient in appropriate community primary care and away from hospital secondary care could have clinical and cost benefits.
There needs to be achieved a consensus such that shared communication between diverse clinical disciplines offers benefits for every patient. Logically, the very diversity of each patient may demand a diversity of clinical therapeutic approaches but working collectively for some patients in parallel pathways.
Sadly; clinical therapeutic tradition, personal beliefs of health providers, politics, (local and professional) with a lack of interdisciplinary awareness of the clinical skills of others leaves the patient far too long kicking the can along a linear pathway towards mediocrity and risk of a compromised therapeutic outcomes.