Nachemson – An exceptional pioneer in back pain research

Lars Avemarie

I have for some years now, been reading articles by back pain researcher and orthopedic surgeon Alf Nachemson. Prof. Nachemson MD is one of the lesser known pain experts, but in my opinion, he deserves a lot more attention, for the great legacy he leaves behind after his death. His pioneering research about back pain and a biopsychosocial approach to pain management has influenced a generation of MDs, health professionals and researchers and his legacy continue to do so.

In 1956 Nachemson graduated (in medicine) from the Karolinska Institute (Stockholm, Sweden) and in the 1960s he earned his PhD at the University of Uppsala, where he also became an orthopedic specialist and associate professor. In 1971 Prof. Nachemson was appointed as Professor and Chairman of Orthopaedic Surgery at Göteborg University, and in the 1950s he was given an assistant research position.

In the late 1960s, Nachemson introduced RCTs in the field of lumbar disc surgery and also did other RCTs on conservative treatment in industrialized settings as well as for back schools, cognitive behavioral treatment and more. In the 1980s Nachemson was one of the initiators of the large epidemiological study of risk factors for reporting of low back pain in the so-called Boeing study.

For 20 years Prof. Nachemson was co-editor of SPINE (a scientific journal) and was also one of the founders of the Cochrane Collaboration Back Review Group. Prof. Nachemson received several major awards from many different parts of the world, for his research and outstanding contributions. Prof. Nachemson published over 500 papers as first author or coauthor, and his research involved more than 20 scientific fields, and more than 20 scientific societies gave him honorary memberships. It is with great sadness that I found out that Alf Nachemson passed away in 2006 at the age of 75.

This is what Prof. Gordon Waddell, MD commented on Prof. Nachemson in 1996:

“He has carried the torch for back pain. He has traveled the world, the centers of power and influence, and spread the message,” and Waddell continued with: “Most of all, he has challenged traditional wisdom and authority, and insisted, demanded that we must do better for our patients with back pain.”

Without further ado, here are 15 quotes from pioneering back pain researcher and orthopedic surgeon Alf Nachemson:

“At the beginning of my career, back pain was regarded as a local anatomic problem related to biomechanical loading. Now we know it is an extremely complex issue that relates not only to local pathology but also to biochemistry, pain physiology, brain science, psychology, sociology, and economics.” Prof. Alf Nachemson, MD

“Many people have focused on the disc as the potential cause of pain. But its role in back pain causation is no more proven than those of other structures” Prof. Alf Nachemson, MD

“I have never been afraid of opposing current thinking and neither should any scientist. If there were no disagreements, we would never move forward as a field. Disagreement is an important part of science.”  Prof. Alf Nachemson, MD

“This experiment has been misinterpreted as evidence that the disc is a significant pain generator and that increasing the biome- chanical load leads to greater pain. But this study merely showed how the lumbar spine responds to normal physiologic loading in various positions of the body. It does not give any indication as to where the pain actually comes from.” Prof. Alf Nachemson, MD

“One of the main goals of my career has been to determine the cause of nonspecific back pain. And in this I have failed. I didn’t know the origin of back pain in those days, and I don’t know now. Many people have focused on the disc as the potential cause of pain. But its role in back pain causation is no more proven than those of other structures” Prof. Alf Nachemson, MD

“One of the major problems still to be overcome is convincing practitioners to apply the results of evidence-based med- icine to their clinical practices. This has proved to be a very slow process. As an example, an RCT that we per- formed at Volvo back in the 1980s—the study by Lindstrom et al.—gave convincing results that quota-based exercise train- ing with a cognitive behavioral approach in the mode of Fordyce could successfully treat workers sick-listed with subacute low back pain. This approach has been confirmed by studies in several other countries. Yet despite the evidence, this method has not gained wide acceptance. Why go through the trouble of performing randomized trials if no one fol- lows the results? If we are going to do the studies, then we must heed the evidence.” Prof. Alf Nachemson, MD

“We have made progress in terms of knowledge but have much further to go. We have solutions for this crisis but haven’t implemented them. The implementation effort will require reeducating the public, patients, primary care providers, orthopaedic surgeons, politicians, and the mass media. We must deal with this crisis at all these levels.”  Prof. Alf Nachemson, MD

“I have been saying for years that we must look upwards to the brain. Though the nociception may occur in the motion segment, the pain is processed in the brain. And, as our research has shown, the pain may change the brain and central nervous system.” Prof. Alf Nachemson, MD

“It is not enough to understand the intricacies of pain from the motion segment to the spinal cord to the brain. They must also be able to understand the psychosocial, socioeconomic, and insurance issues that surround the patient.”  Prof. Alf Nachemson, MD

“We did a series of studies with Volvo and redesigned an entire plant to minimize stress on the spine—based on biomechanical principles. We found that ergonomics just didn’t work as a preventive intervention. It didn’t alter the level of sickness absence due to low back pain at all. And other scientific studies have failed to demonstrate a benefit for ergonomics as a primary intervention. This eventually led to the Boeing study in Seattle and collaboration with Will Fordyce, the psychologist, where we showed for the first time that psychosocial factors play a significant role in back pain. To our surprise, they were better predictors of work disability than physical factors. This study opened my eyes, and those of the world, to the fact that back pain isn’t only about the spine, it is also about the brain.” Prof. Alf Nachemson, MD

“When I began my career, health care professionals and the general public held a variety of mistaken beliefs about back pain.There was a widespread belief that back pain was caused by the physical stresses of work and that it was inherently disabling.There was a belief that back pain would not go away on its own and required treat- ment. It was thought that bed rest and inac- tivity should be the mainstays of therapy.Physicians held the view that patients should stay away from work and physical activity until the pain was gone; and that early return to work and activity would be dangerous for the spine.These all turned out to be myths. All have been partially or completely disproved. But we need to finish dismantling them.” Prof. Alf Nachemson, MD

“we can now offer effective, evidence-based advice to individuals with back pain: go on with normal living; try to find ways to move around and stay active; don’t see a doctor unless the pain is severe; don’t go to bed and rest; continue to go to work. As I have said previously, back pain is an overrated discomfort. Patients make too much of it. So do medical professionals.” Prof. Alf Nachemson, MD

“We live in a society that dreams of a pain-free life. But that is not going to happen. Back pain is a normal part of living. It shouldn’t be the focus of life. It shouldn’t be disabling. It should be thought of as something that will go away and not cause severe problems.” Prof. Alf Nachemson, MD

“Since we don’t know the specific causes of most forms of back pain, we have to rely on RCTs to determine which treatments work. There was initially some resis- tance to the idea of RCTs and systematic reviews in this field. But now there is almost universal agreement on the need for this type of research, particularly since payers have adopted evidence-based methods in reimbursement decisions. There has been tremendous growth in the number of RCTs performed in the spine field.” Prof. Alf Nachemson, MD

“First and foremost, they should develop a thorough knowledge of study methodology and evidence-based medicine. Researchers must be able to determine if their ideas are good or bad. Clinicians must be able to identify which treatments are effective and which should be discarded. They should learn how to test ideas, evaluate hypotheses in a scientific man- ner, and learn where the evidence lies. And they should be able to formulate their arguments and justify their treatments in terms of evidence-based medicine. This is the language of medicine now.” Prof. Alf Nachemson, MD

 

Ref.:

Rydevik B, Hansson T, Szpalski M, Aebi M, Gunzburg R. Alf Nachemson, MD, PhD, 1931-2006: an exceptional pioneer in spine care.Eur Spine J. 2007 Mar;16(3):303-5. Epub 2007 Feb 14.

A Tribute to Alf Nachemson: The Spine Interview. The BackLetter, Volume 22, Number 2, 2007. Lippincott Williams & Wilkins.

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