Your Aching Back

When it comes to back pain, things are not what they seem. For example, your spine might have a herniated disc, without your even knowing it—up to 35 percent of us have the bulging or ruptured discs, without feeling any pain.

But, if you do have back pain, and an MRI shows that you have a herniated disc, that doesn’t mean the herniated disc is causing your back pain. The pain’s provenance may remain a mystery.

That, according to Diane Dalton, is just one of the many quirks of low back pain—all reasons health care practitioners should stop being so quick to order MRIs and prescribe catch-all medications.

Dalton, a Sargent College clinical associate professor of physical therapy and athletic training, teaches in the Doctor of Physical Therapy program and treats patients at BU’s Ryan Center for Sports Medicine & Rehabilitation. An orthopedic certified specialist, she’s also a proponent of a new and more targeted, methodical system of managing back pain, one grounded in evidence.

“My biggest interest is changing practice,” says Dalton. “Low back pain is very common. As many as 85 percent of adults will have at least one major episode of low back pain in their lifetime. So it’s pretty prevalent. And the practice for treating it is very, very varied. That doesn’t speak well to our ability to treat something that’s so common.”

Because the spine is such a complex structure, and low back pain is seldom attributable to any known pathology, the conventional reliance on patho-anatomical diagnoses has proven inadequate, Dalton says. Primary care providers and physical therapists will have more success using what’s known as the treatment-based classification approach to low back pain.

In this system, clinicians sift patients into subcategories, and treat them according to what has been shown to work for other people in the same grouping (that is, other people with the same combination of symptoms and characteristics).

Patients are sorted into these subtypes based on data gleaned through a meticulous regimen of inquiry and investigation (patient history, detailed questionnaires, movement tests). In the relatively few cases where certain “red flags” pop up, Dalton says—for example, in addition to back pain, the patient has also experienced rapid weight loss or bladder control problems—then he or she may be referred to an appropriate specialist to test for cancer or other serious conditions. But for the majority of cases, the focus is on determining combinations of variables such as “the location of the pain, whether the onset is recent, the patient’s age,” Dalton says.

For example, a study published in Annals of Internal Medicine in 2004 demonstrates that patients who had experienced pain for less than 15 days, had no pain below the knee, and had a hypomobile (stiff) spine—and only patients with those traits—benefited from a manual manipulation therapy called a grade 5 thrust, which physical therapists use to mobilize sections of the spine. So now, physical therapists can reliably predict that patients who match that profile are likely to benefit from that manual manipulation therapy.

“It’s an actual change in the way we look at something, from start to finish,” says Dalton. “The treatment-based classification was first described by Anthony Delitto and colleagues in 1995 and has been tested and altered over the years. Still, its use is not as widespread as we would like it to be.”

But Dalton is one of a growing number of adherents. And she’s not only using the system to help her patients at the Ryan Center, she’s also disseminating the research among the future clinicians who are her students.

Furthermore, Dalton has begun a continuing education program to spread the word to veteran therapists as well. In weekly meetings last summer, she guided groups of working clinicians—many of them her former students—through the latest literature.

“One of the things I try to teach my students is that it isn’t simply about what they’re learning this minute,” Dalton says. “It’s also about staying up with the constant developments in the field, because what I teach this year is different from what I taught last year; probably only a small amount, but a lot different from what I taught ten years ago.

“And this particular area, low back pain, because of the costs associated with it to our country”—billions of dollars every year—“has tons and tons and tons of research looking at it. So what we should be thinking about and doing changes all the time.”

Keeping up with those changes is hard for the average, harried therapist. But “one of the great things about the system at BU,” Dalton says, “is that it’s easy for [teaching faculty] to team up with clinicians up the street [at the Ryan Center], and for clinicians to come down and teach in our labs, so the students are getting some real-life experience and guidance, and the clinicians are getting really good firsthand knowledge and staying up-to-date with the field.”

And ultimately, Dalton adds, “the patients benefit.”

Patrick L. Kennedy can be reached at plk@bu.edu.

A version of this article originally appeared in the 2010 edition of Sargent College’s Impact magazine.