low back pain…the new way to treat

Friday, February 17, 2017

Emergency doctors get it. The patient arrives in the ER complaining of pain and wants relief. What the patient does not appreciate is that by having a complaint of pain, he has unleashed a battle between the practice and the business of medicine. The practice of medicine would want the doctor to find the reason for the patient’s pain, fix the underlying cause and also help alleviate suffering. The business of medicine would want the customer’s wants and needs addressed and have superior satisfaction scores. But what should happen if the patient and the physician differ as to what should be done regarding the matter of pain control? It’s not like the patient has a choice of who they get to see in ER, and the doctor really doesn’t have a long-term relationship with the patient.

If only patients were as easy as Kansas City Royals’ pitcher Brian Flynn. He fell through his barn roof, fracturing three vertebrae in his back ,along with a rib for good measure. Pain control decisions in trauma are easy. Broken bones hurt and they take time to heal and the odds are that he’ll miss spring training. At least in the short-term for trauma, pain medication is appropriate to be prescribed. But what happens when there is no trauma?

Guidelines from the American College of Physicians published in February 2017 address treatment options for those with acute, subacute and chronic low back pain. They do not apply to trauma patients. They also do not apply to patients with sciatica, inflammation of the sciatic nerve, that causes pain to radiate down the leg. And they do not apply to patients whose spinal cord is potentially at risk and have bowel or bladder symptoms. But for everybody else, and there are a lot of people with low back pain, the message is clear: try heat or exercise or complementary medical care (think yoga, tai chi, massage or manipulation) because medication as a first line treatment is no longer recommended.

What a shock to a patient who wants immediate relief! It is likely not going to happen. Most back pain gets better in 6-12 weeks and the advice from the College of Physicians seems to be “a little pain never hurt anybody”.  Imagine the ER visit for backache:

  • First step and most important, the doctor talks to and examines the patient to make certain a disaster situation does not exist, things like spinal cord compression, aortic aneurysm, kidney stones.
  • If it’s “just “ low back ache, x-rays, CT or MRI are not initially indicated
  • Treatment recommendations will include heat and perhaps referral to physical therapy or a chiropractor
  • Acetaminophen (Tylenol) is no longer recommended
  • Ibuprofen (Advil, Motrin) or Naproxen (Aleve) might work, but patients with kidney disease, gastrointestinal disease (reflux, ulcers, inflammatory bowel disease) or who are on anticoagulation (blood thinning) medications, cannot take these drugs
  • The patient will be discharged home with no prescription for medication and likely in the same amount of discomfort as when they arrived
  • The patient satisfaction survey arrives in the mail and now the business of medicine hinges on whether the doctor was able to educate and persuade the patient about “a little pain…”

If the low back pain persists, there are some medication recommendations to use as second line treatment, including duloxetine (Cymbalta) an antidepressant medication that affects serotonin metabolism or tramadol (Ultram) a narcotic that according to the World Health Organization has a lower potential for misuse, abuse and dependence. Tramadol not only works on the opioid receptors in brain but also on the serotonin receptors as well. Opioids should only be considered after all other options have failed and only “after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence.) 

The practice of medicine and the role of the patient is gradually changing. Patients are becoming active participants in decision making regarding diagnosis and treatment. But as research and guidelines evolve, the delivery of pain free recuperation may no longer be a valid expectation for the patient or a goal for the doctor. The problem is that pain is very subjective and its tolerance varies from patient to patient. Both patient and doctor will have to learn how to balance suffering with acceptable pain and how to minimize the use of pills to fix things. While the guidelines address back pain, they are likely the tip of the iceberg as more research tries to give direction to pain control in general.

The three recommendation are listed below…and by the way, the guidelines appear to classify tramadol differently than a narcotic or opioid but according to the Federal Drug Administration (FDA), it is just that.


Recommendation 1:

Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)

Recommendation 2:

For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)

Recommendation 3:

In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. Grade: weak recommendation, moderate-quality evidence.) 


Image attribution: www.breakingmuscle.com




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lessons from the super bowl

Monday, February 6, 2017

At Super Bowl half time, the New England Patriots adapt to the reality of their situation, losing by 25 points and to win, they will have to overcome the greatest deficit in the game’s history. At the same time, the Atlanta Falcons will have to maintain the performance and momentum that allowed their lead to accumulate. The Patriots adapt and prevail and there are lessons in patient care that can be learned from the game.

A sure thing doesn’t exist

Patients and families always ask about the odds of what might happen next. Whether it is a heart attack, stroke, infection or surgery, people want the future predicted. Statistics can help guide decision making and suggest who might do better or worse, but until the dust settles, nobody really knows. Ultimately, the patient will do well…or they won’t.

The Patriots overcame the largest deficit ever to win the Super Bowl. They weren’t supposed to win. In-game statistics suggested that the Falcons had a greater than a 97% chance of winning with less than 5 minutes to go.

Every doctor has a had a patient who was doing well, recuperating from a procedure or recovering from an infection, when minutes later, without warning, they crash: blood pressure drops, heart and breathing rates spike, the patient becomes unconscious and quickly dies. No reason, no warning…bad karma.

There’s always hope

The corollary to an unexpected patient crash is the patient who seemingly has no chance of recovery and almost miraculously wakens to walk out of the hospital. Ironically, while these experiences can give hope to patients, families and doctors, the reality is that patients who are in end-of-life situations most often die.

Sports fans almost never give up hope, whether their team is down by 25 points or needs a miracle to make the playoffs, hope springs eternal. Many Patriot fans, including President Trump, were reported to have not watched the last half of the game because of the presumed forgone conclusion.

The issue in medicine is that sometimes care can be futile, causing pain and suffering for the patient. It can be very difficult for a doctor to present that situation to the family, especially if a crisis arises quickly and there has been no time to prepare. The doctor remembers that one patient, years ago, who miraculously survived.

It’s usually more than one thing

When a patient does poorly, it is usually more than one event that causes the situation to deteriorate. The body’s many systems are closely intertwined. An illness or injury causes the body to turn on its response systems but some diseases inhibit the body’s ability to react. Diabetics and patients who take medications that decrease immunity may have a hard time generating a response to infection and stress. Some heart medications inhibit the body from reacting to blood or fluid loss. Every patient is unique and as the body ages, it loses gradually its ability to overcome the stress of illness or injury.

Sportswriters, radio talk show hosts and a variety of analysts and experts try to define the one play that allowed the Falcons to collapse, but it was more than a Ryan fumble, or an Edelman catch. Perhaps it was a well-placed Patriot kickoff or a sack in the last few minutes of the game. More likely, it was a combination of all. Each by itself is not a catastrophe, but together, they changed the tide of the game.

Medicine is the same way. Patients can tolerate one or two system failures but keep adding malfunctions and the body reaches a point of no return. When things go bad, the body is programmed to sacrifice less important organs, to allow the brain to survive. The body is happy to maintain circulation to the vital organs (think heart, lung, liver, kidney and of course brain) to the detriment of all else. If one or more of these organs is already compromised, the body has a decreased ability to respond and recover.

Finding the scapegoat

The Patriots won as a team and the Falcons lost as one as well. There may have been individual efforts or decisions that were in the spotlight, but many events had to occur both good and bad, that resulted in the outcome of each play. Tom Brady might have been given time to throw a pass because of an exceptional effort by a lineman. A defensive player may have occupied two blockers to allow a teammate to make a tackle. The purpose of film review is to find the small things that can lead to big differences both  positive and negative and game plan fro the future.

When a patient develops a complication, a similar review happens in the hospital. M&M rounds, morbidity and mortality, demand that adverse patient outcomes be presented in an open forum for discussion. It is a learning environment, where medical care is reviewed to see whether warning signs of impending badness were missed, whether the outcome was inevitable or whether the patient just had bad karma. Bad outcomes can happen, even if everybody does the right thing, but the review has to happen. Medical care can’t get better unless doctors ask why.

Sport is life

We learned many lessons from this historic Super Bowl and not surprisingly, they are as applicable to medicine as they are to football. And just as likely, they apply to everything else in life just as well.

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