Our office utilizes the highly acclaimed Back Power Program to help rehabilitate weak backs. The following is a book review by David Chapman Smith in his publication The Chiropractic Report.

By David Imrie, M.D. and Lu Barbuto, D.C., Stoddart Publishing,Toronto, 1988.

This is the first comprehensive work for the lay public co-authored by a chiropractor and a medical doctor. It reports on "Back Power", a comprehensive program for the assessment of low-back problems evolved during the authors' work together over 10 years from 1978.

Imrie, aged 43, is an occupational health physician who is the most prominent Canadian medical expert on industrial safety and prevention. He is a consultant to the Ontario Workers' Compensation Board, one of the largest in North America, and is retained by the safety associations representing construction, electrical utilities, farming, forest products, mines, transportation, and various other smaller sectors. His Back Care Centre, a multi-disciplinary centre in which a chiropractic clinic is an important component, serves 70 local industries and 30,000 workers.

Barbuto, who has worked with Imrie since 1978, has an independent practice in Toronto. In recent years he has been Director of the Canadian Memorial Chiropractic College Clinic in West Toronto, prominent in undergraduate and postgraduate education particularly in the field of occupational health, and since 1986 has been retained by the Ontario Workers' Compensation Board as chiropractic consultant.

There is nothing dramatically new about the Back Power program from a chiropractic perspective. However, the importance of the book is that it:

• Represents a new approach to medical management of back pain, advocating cooperation with the chiropractic profession.
• Has the traditional chiropractic emphasis on function rather than pain or disease pathology, focuses on the asymptomatic back and declares "that back pain in 90% of cases is the failure in management of back health."
• Gives equal emphasis to management of joint and muscle function in a program with new integration and detail.
• Gives the public clear advice on self-management and testing of back muscle function.
• Gives fundamental importance to chiropractic theory, practice and research on low-back pain.

Origins of Program

The evolution of the program, as explained in the book, is of great interest.

- Dr. Imrie moved from general practice to an industrial health practice in the 1970's. Back injury became the dominant part of his practice. He was failing on the basis of his medical training. He was looking at the symptom of back pain, seeking a diagnosis, then trying to remove the pain. His traditional neuro-orthopaedic assessment tools indicated pathology in under 10% of cases.

With the other 90% he was helpless. When pain ceased he would certify the patient fit for return to work. Within weeks many of them were disabled once more. This represented a clear failure, and convinced him of the need for an alterative approach. He decided to investigate the roles of muscle and joint function, fields outside his training as a physician.

His interest in muscles arose in part from the training of his sister as a physiotherapist, and her experience with back school. It also arose, as he explains, from the work of a local rehabilitation specialist, Dr. Terry Kavanagh, in caring for heart recovery patients.

Kavanagh became internationally famous when a group of his patients completed the Boston Marathon in 1973. At a time that traditional medicine was telling heart attacks victims to avoid exertion for the rest of their lives, Dr. Kavanagh produced an exciting effective low-tech alternative - commencing a controlled diet and graded exercises until patients could run a marathon. If muscle conditioning could do so much for heart function, reasoned Imrie, why not for backs.

Results showed that improved muscle function alone was insufficient.

- Where was Imrie to go to learn about joint function? He had heard criticism of chiropractors at medical school, but many of his patients swore by them. He had no personal experience. "I mustered my courage and phoned the chiropractic college in Toronto", asked to speak to a competent young chiropractor, and was given Dr. Barbuto. Within weeks they were working together, two mornings and one evening each week. His Back Care Centre thus had the ability to evaluate and treat joint function, and the full Back Power program was born.

The Back Power Model

The Back Power model starts with the premise that everyone should test for back function regularly, regardless of whether or not they have ever experienced back pain. The essence is:

1. If you have back pain, or a history of back pain, you should seek professional advice to determine whether you are one of the relatively few with pain from organic disease, or one of the more than 90% with mechanical dysfunction.
2. If you have no history of back pain, or pain from dysfunction - i.e. almost everyone - you should do a simple chair test (rising with arms folded) to indicate whether you have a pelvic ring disorder as described. (A large number of those experiencing pain, or not yet in pain, will.) If so you should seek professional advice, and Imrie and Barbuto explain the role and importance of chiropractic motion palpation. If you pass the chair test you are likely to be able to help yourself.
3. With respect to muscle function, what is important is strength and flexibility of the four main trunk muscle groups themselves. (Back muscles, abdominal muscles, sling muscles or hip flexors and lateral muscles). People can test strength and flexibility themselves. Appropriate exercises and a point grading system are given, which lead to an aggregate muscle dysfunction mark. Specific advice is given on exercise and lifestyle to improve each area of poor muscle function. There is also advice on when to stop, when to recognize that joint problems may be a factor, and when to seek professional help.
4. With respect to joint function "... bony elements are static and much more difficult for personal management... improvement of joints can only be a health professional's responsibility."
5. When professional help is needed for treatment of dysfunction rational management is based on a back power functional model (see Fig. 1) which presents four rational bases for treatment:

• Joints too tight and fixed - appropriate treatment is to restore movement through adjustment, mobilization or manipulation.
• Joints hypermobile (too mobile - relatively uncommon) - restore normal movement through external support, surgery or improved muscular strength.
• Muscles too short (tight) and weak - lengthen them through stretch/relaxation exercises or yoga.
• Muscles too long and weak - tighten through power exercises or weight lift

It It is emphasized that several dysfunctions may be found "and the approach is thus to try to restore all of them as much as possible toward normal function ... recognizing that the pain symptom usually results from the cumulative effect of the several dysfunctions and not from any one of them in itself." There is explanation of how joint hypermobility at one spinal level may be secondary to fixation at others.

On this model rest, medication, heat therapy and electrical therapy are all of secondary importance - they are merely palliative treatments to alleviate some immediate pain, and are not working on the cause of the problem.

All aspects of this back power model are illustrated with case examples.

General Comment

There are many passages that will be music to the souls of chiropractors. Examples:

• This book for the lay public commences with Dr. Imrie commenting on the Wilk Case, quoting the terms of the court injunction issued against the American Medical Association, and explaining how disagreement between the chiropractic and medical professions is contrary to his experience in practice and quite unnecessary. He then deals with and dismisses some common medical criticisms of chiropractic, confirming that he now knows chiropractic education - in all respects except for the absence of pharmacology - to be the equivalent of undergraduate medical education.

(In an interview with us, Imrie noted that when he and Barbuto met, "Lu could discuss medicine with me, because he had all the same basic sciences and background - but I was quite unable to discuss chiropractic with him.")

• There is colorful use of analogy. Pain from loss of back function is said to be like eye strain and headache from loss of eye function - a problem of weakness and function not disease. Sacroiliac strain leads to a `back attack' and pain, in the same way as diminished vascular function (through increasing clogged arteries) leads to `heart attack' and pain. A remedy must be sought before arrival of pain, which is the end point of the problem.
• Constantly there is rejection of the "traditional approach" of asking "what is causing the pain and how do I get relief from it" and seeking "quick fixes for symptomatic pain relief rather than.... making a meaningful diagnosis and correcting the underlying problems which are causing the pain."
• In the book's introduction, Barbuto defines chiropractic as "the study of problems of health and disease from a structural point of view with special consideration given to the mechanics of the spine and its neurologic relationship."
• Elsewhere he gives appropriate emphasis to other aspects of the chiropractic model of health -homeostasis, the link between the whole body and neuromusculoskeletal holism, and what the patient must contribute himself/herself.
• Barbuto and Imrie close their introduction with this comment:

"We've come to the conclusion that health is no longer the exclusive domain of one profession. Rather, by challenging current concepts and taking an interdisciplinary approach to the problems associated with the diagnosis, treatment and management of back pain we have arrived at our mutual goal. Helping you to help yourself to be the best you can be whether or not you've ever experienced back pain."

Back Power is going to reach many people,and be influential in the increasing public and medical understanding and acceptance of chiropractic. You will want to read it. By this time next year many health professionals are going to be consulted by patients who have read Back Power and know rather more than they the professionals do about the rational management and treatment of common low-back pain.

The Back Power Plus program has been used extensively in Canada for the last six years with excellent results.

Companies using the program have reduced their back related compensation costs by up to 90%.

After review of 54 back injury prevention programs, the National Safety Council chose Back Power as the premier back safety program, and endorses the Back Power Program. Back Power is also endorsed by regional safety councils in the U.S. and Canada, and the Ontario Worker's Compensation Board.

THE RESULTS

Decreased healing time, less suffering, less disability, and control by the patient of his or her back problem are all among the benefits of Back Power Plus. This in turn dramatically reduces recurrence, which is so common with back injuries, and the cause of so much unneeded human suffering.

BACK FACTS

Back pain is the leading cause of worker disability under age 45. Recurrence of back injuries within two years is consistently around 50%.

In the United States, 33% of the work force will miss time on the job due to back injury.

In a recent University of Toronto survey, 62.9% of Canadian M.D.'s stated that they referred to chiropractors.

The per capita rate of low back surgery in the U.S is 10 to 20 times the rate of surgery in any other industrialized nation.

Back injuries cost American industry over 50 billion dollars in 1982.

William Kirkaldy-Willis, M.D., an orthopedic surgeon and researcher estimates that over 90% of back pain is mechanical in nature and should respond to chiropractic care.

We will train you and test your progress with the Back Power Program during your corrective care phase. Many of our practice members find stubborn painful back problems stop recurring after the implementation of Back Power.

Karl R.O.S. Johnson, D.C.

Imrie-Barbuto Occupational Consultant