Instigators of activity intolerance

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 recommendations 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 'pathologically'/clinically painful.The Task Force's proposed 'demedicalization' of non-specific low back pain (NSLBP) together with the endorsement of (chiropractic) 'manipulation' will probably help reduce the immediate costs of invasive treatments and/or hospitalization as well as the deconditioning consequences of prolonged inactivity. However, it is contended that, in the longer term, it would also be necessary to deal effectively with maladaptive fear-avoidance 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 'demedicalization' 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. Copyright 1997 Harcourt Publishers Ltd.