“We need to maintain a non-surgical approach in orthopedics”

Orthopedic engineering is an important arrow in the quiver. Professor Dr. Bernhard Greitemann, Medical Director at Münsterland Hospital, Germany, and one of the authors of the guidelines for treating non-specific low back pain, talks about multi-modal pain therapy, team work and discussing evidence.

life: Problems with the lower back – why is back pain so common?

Professor Dr. Bernhard Greitemann: To some extent, it’s based on evolution. The S-shaped spine has developed to allow for an upright gait. Its enhanced cushioning effect is an advantage. It has the disadvantage, however, that it makes the transitions from fixed to mobile skeleton elements more vulnerable. That is also where other problems with the musculoskeletal system manifest. About 4 of 5 patients we treat suffer from back pain. This doesn’t just include spine patients but also those with a total knee or hip replacement. The biggest problem is, however, that there is an increasing lack of active exercise. Our sedentary activities result in deconditioning and support a vicious circle of pain. The COVID pandemic has added fuel to the fire. That’s why any treatment strategy should encourage back pain patients to return to activity. In this context, sports clubs are important for prevention, and they need to be supported.

What challenges are associated with the diagnosis of non-specific back pain?

Professor Dr. Bernhard Greitemann: Non-specific back pain is a black box. What can we do without harming the patient after red flags, such as a tumor, trauma, herniated disk, osteoporosis and similar conditions have been excluded, and no clear cause can be determined? Muscle and ligament dysfunctions can be triggers, but those can’t be detected with imaging technology. Stress, bullying at work or a lack of resilience are also frequent factors, particularly with chronic back pain. Many patients will unwittingly escape into somatic problems if things aren’t going well at work or in their private lives. Therefore, if non-surgical pain therapy with medication, physiotherapy and orthopedic engineering doesn’t show any improvement after four weeks, a specialist should examine the psycho-social risk. Here, we can rely on screening tools, such as the Heidelberg or Örebro questionnaire. In our rehabilitation clinic, we use a multi-modal program comprising six exercise-related and six psychological units. Back treatment is a team effort. Physicians, sports therapists and psychologists take part in our sessions to allow them to get involved at different stages during pain management. This includes an introduction to exercise, perception training and, a highly important component: education on how to implement behavioral changes.

Is that one reason explaining the inconsistent evidence when it comes to the use of orthopedic aids?

Professor Dr. Bernhard Greitemann: It’s one of several reasons. For some meta analyses, the comparability of the results must be critically questioned. What kind of differential diagnoses were there? What types of braces were prescribed? Does their active principle fit the indication? These aspects are often not taken into consideration, but they’re crucial for possible treatment success. In cases of facet syndrome, for example, stabilization is required, but reclination must be avoided. That’s why a brace supporting flexion is better in this case. Not enough physicians know the active principles of back braces. If, in addition, the diagnosis is not completely definitive, often no prescription or no targeted prescription will be issued. What’s more, it’s the overall package of measures that helps combat back pain. During studies relating to multi-modal treatment, individual aspects cannot easily be proven because the concept is too complex. I was involved in the development of the German national guidelines for treating non-specific low back pain. We could have recommended the potential use of braces. But that wasn’t possible because, as a prerequisite, it was defined in advance that only activating treatment options would be included as useful. Braces, however, have an indirectly activating effect, as opposed to therapeutic exercise, because you can start training earlier and do more when the pain subsides thanks to the external stabilization provided. My experience has been that braces help with pain therapy – in a non-surgical, post-operative and an educational setting.

What about patient compliance?

Professor Dr. Bernhard Greitemann: To ensure patient compliance, it’s really important that the physician explains in detail why a specific product is prescribed. This creates trust. Patients want to be heard and taken seriously.

Images: shutterstock.com/Elena Kharichkina, Sven Hillert