In the 1920s and 30s, heart disease was considered so volatile and dangerous, and patients so vulnerable and fragile, that the best medical advice was to put the patient to bed and allow them to rest.
Rest gave doctors and nurses the opportunity to stabilise the precarious cardiovascular system – a system that was hardly known at all – and keep the patient under surveillance. The goal was to prolong life and reduce the incidence of further illness. Recovery seemed an unlikely outcome since any movement might send the heart into a new crisis.
Attitudes began to change in the 1950s though, as the incidence of heart disease in America and some European countries became a real concern. New invasive procedures, imaging, and stress-testing on the cardiovascular system showed the heart to be more robust than people had long thought. Suddenly the cardiac patient moved from being a fragile victim to a resilient survivor. The answer now lay in rehabilitation, not rest.
The heart-healthy exercise boom that took off in the 1970s, and the new trend towards exercise as a therapy and prophylactic for heart disease, stands alongside smoking cessation and better diets, as one of the most significant public health shifts in the last 50 years.
It is interesting to see the parallels now, then, with the drift away from rest and passive treatments for back pain, and more active, exercise-based forms of management.
Although a lot of evidence is now being mobilised to suggest that earlier approaches don’t work, the reason for the shift in approach may be more about a cultural shift in the way we see people with back pain as fragile.
Evidence showing that there is little link between underlying pathology and people’s symptoms has cast doubt on the way health professionals have catastrophised back pain, and encouraged the feeling of passivity and dependence on the heroic therapist or doctor.
Governments are desperately keen to reduce the incidence of back pain in the population, and one of the key ways to do this is to shift the publics’ perception of their condition.
We have seen this in the years leading up to World War I when injured servicemen were increasingly encouraged to take responsibility for their own rehabilitation and future work (Beth Linker’s War’s Waste is a fabulous account of this). And, of course, we’ve seen it in the way heart disease was redefined.
Back pain is one more location where shifts in social attitudes are now being played out.
I wonder if some of the historic fragility of low back pain could be attributed to the Victorian idea of ‘body is a machine’ where the biomechanical lens looked at the junction of the lumbar spine and the pelvis as a critical stress point and thus considered a weakness in body design as we evolved into bipedal beings.