Monia Lusini comments on a recently published study about patient’s perception of back pain

How well can the clinician appreciate the patient’s perception of the severity and impact of their back problem?” was recently published in the European Spine Journal. The study was carried out in two collaborating centres (in Switzerland and Italy) and involved five consultant spine specialists and 108 of their patients who had presented for treatment due to a low back disorder.

This cross-sectional study compares patients’ and physicians’ ratings made on the same day of the consultation for treatment.

Let’s make a premise. Good doctor-patient communication allows patients to share vital information regarding the nature of their problem, which is essential for an accurate diagnosis.

“Effective communication has been associated with improvements in patient satisfaction, greater adherence to treatment plans, better and more appropriate medical decisions, and improved clinical outcomes, ” explains Dr. Monia Lusini, an orthopaedic doctor and one of the research study’s authors. One of the main concerns of patients with back problems is typically their back and/or leg pain (together with its origin) and its impact on their function and quality of life. These subjective data must be considered during the visit so that the specialist can verify their impact on the patient’s daily life and decide on the best treatment path.”.

The study evaluated the agreement between clinicians’ and patients’ independent ratings of patient status on the Core Outcome Measures Index (COMI). The Core Outcome Measures Index for the back (COMI back) is a short, validated, multidimensional outcome instrument with excellent clinimetric properties.

The study shows that doctors could ascertain the location of the main complaint of their patients with good accuracy; however, they systematically underestimated the severity of the patient’s leg pain and dissatisfaction with their current symptom state and overestimated how much the patient’s function was impaired.

This is probably because at the time of the visit, the patient is no longer in the acute phase of pain and functional impotence that he was forced to experience in the previous days, but the memory is still vivid. Often, it is the patient himself who is amazed at how he can move during the visit compared to just a day or two before.
The COMI questionnaire is, however, fundamental for these patients to understand the difference in quality of life and pain before and after the prescribed and performed therapy.

“More detailed or direct questioning on these domains during the consultation might deliver a better appreciation of the impact of the back problem on the patient’s daily life,” concludes Dr. Lusini.”

Scoliosis: what positions to sleep in?

The determination of parents, and patients, to find ways of counteracting the progression of scoliosis often leads them to come up with questions, and to look for as many new strategies as they can.

One of the issues they raise concerns the awkward and “twisted” positions that children and adolescents tend to adopt when relaxing on the sofa or bed, or when they are writing, and so on. 
Do these positions affect scoliosis in any way, and can they even cause it?  

To answer these questions, let’s start by making a few key points clear. First of all, scoliosis is a disorder that causes deviation of the spine in the three dimensions of space, and it shows a natural progression; in most cases, it first appears in the early phases of growth. Posture, like the positions a person assumes in daily life, may affect the condition, but only to an extent, and they do not trigger or cause it.

This deviation of the spine, which throws it out of line, results in non-uniform loading of the spine and can therefore drive what is known as Stokes’s vicious cycle (asymmetrical loading causes asymmetrical growth leading to progression of the deformity…).

Conservative therapeutic approaches, consisting of specific self-correction exercises or brace wearing, aim to reduce this misalignment of the spine, counteracting the natural worsening of scoliosis and allowing more physiological growth of the anatomical structures of the spine.

When we are seated or standing, spinal loading is an important issue: in these positions, the force of gravity acts vertically on the whole of the spine, causing it to be more compressed and therefore more susceptible to developing an asymmetry.
Instead, when we are lying down, be it on our back, on our front or on our side, there is much less loading of the back, as the force of gravity is no longer pushing down on the spine, but distributed horizontally over the entire body. 

During the night, precisely because we spend a number of hours lying in bed, with our backs unloaded and no longer subject to the stresses generated by loading and movements, our spine is able to “recover”: the discs situated between the vertebrae are rehydrated, and the entire spine lengthens.   

You may well remember your parents remarking of a morning, “Goodness, you’re so tall! You seem to have grown overnight!” .
Well, as it happens, there is a physiological reason for this. Some studies suggest that we can gain up to 1-2 cm in height as an effect of these nocturnal regenerative phenomena. However, this extra height is lost in the course of the day, and with the passing of the years.   

In conclusion, in the light of what has been said above, and also bearing in mind that we have no control over the positions we adopt when sleeping, our advice to patients is to carry on sleeping in the positions they find most comfortable, because there is no such thing as more or less correct positions during sleep.
Just make sure that the surface supporting your mattress (usually slats, metal bedsprings or a flat platform) ensures that it remains parallel with the ground, and that the central part does not sag. If you sleep in a brace, this isn’t even an issue, as your spine will remain correctly aligned whatever position you sleep in.

It is important to have an active lifestyle, do sport and, for those doing rehabilitation treatment, to follow the prescribed programme of physiotherapy exercises and/or brace wearing.
A final piece of advice: try not to spend too much time lying on your bed or on the sofa, unless it is to rest or watch something on TV! 

Flat feet and Scoliosis

Scoliosis is a complex structural deformity of the dorsal spine in all three planes of space. Frontally, scoliosis is identified as a lateral bending of the spine, from the side (sagittal view) as an alteration of the spine’s physiological kyphosis and lordosis (i.e. natural curves, which can appear reversed), and axially as a rotation of the spine.

A flat foot, on the other hand, is a dysmorphism where the anatomy of the foot is altered: the plantar arch is less prominent than it should be, and increases the weight-bearing surface of the foot.

In babies and toddlers, flat feet are physiological (perfectly normal), being observed in nearly all children aged from 0 to 2 years (97%), before becoming progressively less frequent as they grow. Around 50% of children still have flat feet at three years of age and 25% at six years, whereas by the age of 10, very few children still have it.
Basically, it takes some time to form the plantar arch and the heel to begin to turn outwards rather than inwards. If flat feet persist in adolescence, it is a good idea to consult a specialist in disorders of the foot.
There are two “alarm signals” that should be brought to the attention of the family doctor, namely, if the youngster has difficulty walking, or if you notice that the plantar arch is not evident when he/she rises on tiptoes. In the literature, it is agreed that walking barefoot (particularly on an uneven surface like ground, grass or sand) stimulates the formation of the plantar arch, by training the different muscle groups involved.  

To date, there are no articles in the literature that actually link the problem of flat feet to the development of scoliosis: some articles just point out that flat feet and scoliosis are problems that can coexist in growing subjects; that said, the majority of the few articles that do mention both conditions refer to subjects with neurological disorders.

Therefore, although a spine specialist may as well ask a patient to stand on a podoscope (in order to carefully assess the pressure areas under the feet), beware of thinking that flat feet can affect the spine or cause it to deviate.