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    Manual Therapy (1997) 22), 75-86 (©1997 Pearson Professional Lid Review article Instigators of activity intolerance M. Zusman Curtin University of Technology; Department of Physiotherapy, Shenton Park, Australia SUMMARY. During the course of this century several Western societies have experienced an insufficiently explained exponential increase in disability due to back pain, Recently the International Association for the Study of Pain’s Task Force on Back Pain in the Work Place summed up the present problem and made recom- ‘mendations for its future management. Management, and possibly prevention, are likely to be assisted by understanding the reasons responsible for this unsustainably costly phenomenon. It is proposed that one such reason involves maladaptive fear-avoidance beliefs and deconditioning behaviour arising out of convictions as ‘to some structural-anatomical-biomechanical (SAB) basis for the pain. Also, these beliefs and convictions may receive neurophysiological endorsement from peripheral afferent input that is normally not registered as being ‘pathotogically'/linieally painful. ‘The Task Foree’s proposed ‘demedicalization’ of non-specific low back pain (NSLBP) together with the endorsement of (chiropractic) ‘manipulation’ will probably help reduce the immediate eosts of invasive treat- ‘ments and/or hospitalization as well as the deconditioning consequences of prolonged inactivity. However, itis, contended that, in the longer term, it would also be necessary to deal effectively with maladaptive fear-avoid~ ance beliefs and SAB-based convictions as to the cause, meaning and management of back pain. In some Western societies (manipulative) physiotherapists may be given the opportunity to be a part of this “demedi- alization’ process. Therefore, it would now be appropriate to consider the issues involved, some of which are raised here, in order to help decide what direction the physiotherapy profession might take. INTRODUCTION benign, and that nearly all interventions do not alter the outcome.” Recently a task force appointed by the International The concept of activity intolerance is applied co both Associaton fr the Study of Pain to report on pain in acute and chronic Tow back pin, 85 percent of which is the workplace recommended that "nonspecifi’ low currently considered to be ‘nonspecific’ (Fordyce 1995). back pain (NSLBP) should cease to be regarded as a The term ‘nonspecific’ means essentially the inability of medical problem and instead reconceptualized as orthodox medicine to arive ata definitive diagnosis for intolerance to activity (Fordyce 1995). Among other pain largely on the basis of siructure, anatomy and things this perspective provided the Task Force with a biomechanics (SAB). The Task Force definition of non- platform from which to deliver proposals for contain- specific back pain is: ‘Back pan complaints occurring Ing, and perhaps reversing, the now monumental and without identifiable specific anatomical or ncurophysio- intolerably costly situation that has developed with logical causative factor” (Fordyce 1995), As one respect to NSLBP, Such proposals include making the spokesperson for orthodox medicine recenty stated medical management of NSLBP time and not pain “The structural paradigm (for low back pain) has not contingent with the potential to relabel patients in the met the challenge.’ (Saal 1995). It should be noted that process. Thus medically “disabled” becomes socially this view is not shared by all orthodox health care Xinemployed' Justification for ‘demedicalizing’ NSLBP providers nor, of course, by so-called alternative is summed up by Hadler (Hall & Hadler 1995): “We providers, in particular chitoprace, Furthermore, itis need to understand that the cause of regional backache highly likely tha, n many Wester societies some SAB (NSLBP) is indeterminate, that its natural history is bass fr spinal pan is favoured by a large proportion of the lay public (Zusman 1984 Cherkin & MacComack Max Zasman,DipPhi, are, Cutin Uaveninyar 1989: Borkan etal 1995). Nena eres tea scks SieesstenonPan, The following paper proposes that, with some indi- G08 Ween fasta viduals, chronic activity intolerance. (disability) i 16 Manual Therapy directly related to cognitively mediated and maladaptive beliefs concerning the SAB cause, meaning and manage- ment of NSLBP. Neurophysiological reinforcement for these beliefs may come, in part, from the encoding and interpretation of mechanically produced peripheral affer- ent input that is aormally not perceived to be clinically ‘painful. Asa result, failure, for various reasons, to obtain acceptable levels and/or duration of pain relief usually in association with the unproductive sequence of providers and treatments, effectively renders these patients chronic, partial or complete activity intolerant ‘cripples’. Moreover, in the absence of better information, some of | the self same factors responsible for short-term positive ‘outcomes also contribute to the increasing numbers of long-term failures, Several lines of evidence tend to endorse this view. The paper begins with an examination of the possible positive and negative consequences of patients and providers, common SAB-based beliefs and Perceptions regarding back pain: likely neurophysiologi- cal sources of potentially misleading mechanically pro- voked ‘pain’ are nominated. It concludes with a discus- sion of the present and future role of manipulation and rehabilitation in the management of NSLBP. PATIENT AND PROVIDER SAB-BASED PERCEPTIONS Spinal pain patients percey Direct evidence regarding spinal pain patients’ beliefs comes from studies such as that by Zusman (1984), Patients were surveyed concerning, among other things, their beliefs as to both the cause of their pain and its actual o anticipated relief following teatment with ‘manipulative physiotherapy. More than half ofthe sam- ple stated that their pain was due to ether, or various combinations of, an intervertebral dse, facet joint, or smascle being ‘out of place’, Not surprisingly the same patients were confident that this pain was, or would eventually be, relieved by competent manipulation of these structures into ther former appropriate anatomical position (Zusman 1984) Similar naive SAB-based beliefs were expressed by subjects in the recent study by Borkan et al (1995). Subjects associated the onset of severe disabling pai with their back being ‘caught’ or having ‘gone out. Predisposition to this perceived SAB-like event was variously attributed to such things as life-long heredi- tary-congenital factors, childhood as wel as subsequent injuries, muscle ‘imbalances’ and potentially harmful postural-ergonomic stresses encountered especially ‘when working. Patients made statements such as: ‘It is obvious to me that there is some (structural) defect. in ay spine. (Borkan et 1995). Significantly, apart from ‘medication, the preferred treatment for this totally immobilizing pain appeared to be spinal ‘manipulation’ Borkan etal 1995) Obviously these setiofogical and_predispositional beliefs and preterred management are consistent with the SAB basis for spinal pain that is identified mainly with alternative providers, specifically chiropractic. However, Zusman’s (1984) study suggests that patients ray also be willing to attribute these beliefs to certain orthodox providers whose diagnostic and/or therapeutic conditions of care appear to them to assume some SAB basis for their pain, and other visible or palpable phe- nomena. One of the reasons this is important is that there appear to be growing numbers of individuals in Westem societies who are decidedly unhappy with orthodox physicians, and prefer alternative providers, ‘when it comes to the management of their spinal pain problem (Coulehan 1985a,b; Cherkin & MacCornack 1989; Curtis & Bove 1992; Reis et al 992; Borkan etal 1995). Also its possible that, forall practical purposes, not just pstients but some authorities might make litle distinction between (manipulative) physiotherapists and chiropractors/osteopaths (Thomson 1995). In the study Borkan et al, onhodox physicians were ‘mistrusted ... and perceived as not to be taken seri ‘ously, both in terms of their knowledge of the problem and the rigourousness oftheir workups and treatment.” (Borkan et al 1995). Patient’ dissatisfaction with ortho- 3months) it becomes increasingly unlikely ‘that persistent pain has the same nociceptive basis (Fordyce 1995). Just what the cause of this chronic non-specific’) pain might be appears uncertain (Waddell et al 1993). Itis probable that a number of so- called psychosocial factors contribute toa complex situ ation in which patients’ suffering and distress. are expressed within the context of pain (Waddell 1987; Frymoyer & Cats-Baril 1991; Main & Spanswick 1991; Barsky & Borus 1995; Pilowsky 1995). It is certainly important that pain is not thought of solely in terms of nociception (Fordyce 1995). On the other hand, simply because (chronic) pain persists‘... beyond normal beal- ing time” and *... there is no longer any evidence of tis- sue damage’, is not to suggest that patients are largely imagining the pain (Waddell etal 1995). Nor that there is no remaining (nociceptive) sensory component to the pain, a notion which Waddell et al (1993) maintain is oth theoretically and clinically unacceptable. ‘Therefore, while the basis for such a subsequent sensory ‘component would be quite different from that which per- tained originally (Waddell et al 1993), itis important that some stimulus-induced neurophysiological process for ‘ongoing pain perception is identified (Fordyce 1995). Central sensitisation ‘The no doubt clinically important phenomenon, central nervous system sensitisation, has been advanced as @ possible autonomous source of the heightened responses that characterize pathological or clinical pain (Wall 1991; Woolf 1991; Zusman 1992). Considerable ‘evidence now demonstrates that for atime following an initial barrage of unmyelinated small diameter periph- etal afferent input to the spinal cord, dorsal horn neu- rones respond to subsequent incoming information in an exaggerated and abnormal manner (Woolf & Wall 1986; Hoheisel & Mense 1989; Neugebauer & Schaible 1990; Torebjork et al 1992; Thompson et al 1993). As a result of biochemical events triggered by substances released from the central terminals of C/Group IV peripheral afferents, dorsal hor neurones which normally only respond to noxious stimuli applied directly to their receptive fields (nociceptive specific neurones), expand their fields and respond to input arising from distant sites and structures (Woolf 1991, 1994). Furthermore, responses can now be produced in these neurones by normally ineffective non-noxious stimuli applied to both some actual pathological site as well as to distant non-pathological sites and structures. Similar exagger- ated and abnormal responses to mildly and noxiously produced input are also observed with other dorsal hom neurones that receive both types of input normally (wide dynamic range neurones) (Wool 1991, 1994). ‘These and other changes in the excitability and behaviour of spinal cord (and supraspinal) neurones fol- owing a barrage of input along small diameter periph- eral afferents are considered to contribute significantly to the various sensory, motor and, hence, behavioural responses seen clinically (Wall 1994). Therefore, it has ‘been proposed that should such central nervous system ‘changes persist for any reason(s), a basis could exist for the continuation of these clinically observed responses in the absence of any recognizable or clinically signifi- cant ongoing peripheral pathology ~ that is, after heal- ing had occurted (Wall 1991, 1994). In other words, a mechanism for the perception and, with ths, interpreta- tion of the cause and meaning of (non-specific spinal) pain arising spontaneously and/or produced as a result of everyday environmental stimuli. The latter might 80 Manual Therapy include mechanical and thermal stimuli that are natu- rally occurring (gravity, climatic) or deliberately created (aily living and work-related postures, movements and environment). As far as patients are concermed any pain 0 produced and processed would be, to all intents and purposes, the same as that experienced earlier during the acute (traumatic) stage. There is evidence to suggest that with some patients and under certain circum- stances, pain may become “centralized” and persist vir- tually independent or in the complete absence of patho- logical peripheral events (Wall 1991; Dubner & Rudi 1992; Coderre et al 1993). Whether such isthe case with the ‘indeterminate’ symptom NSLBP is not clear (Halt & Hadler 1995, Fordyce 1995), Other evidence indicates that, in keeping with the

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