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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back pain

Tuesday, October 28, 2014

Fans always want to know the ins and outs of NFL injuries. Understanding what happens on the sidelines or in the locker room may help their fantasy football predictions or perhaps satisfy their prurient interest, like slowing down when driving by an accident, but it also engenders a false expectation of what the real world can bring to medical care. If technology was used on every person with a back injury like it was on the Cowboy’s Tony Romo, Medicare would be in a deeper financial hole than it already is.

Admittedly, even for an elite athlete, Mr. Romo’s case is special. Last year, he required surgery to repair a ruptured disc in his back and he has had to limit his practice time so that he could play on Sundays. Still, the Cowboy nation held its breath when he lay on the turf after taking a knee to his low back when being tackled. After x-rays in the locker room were negative for broken bones, he came back to play. But physical exam, those x-rays and clinical judgment weren’t enough. Technology and an MRI was required to confirm the decision as to whether he could return to play.

More than 85% of the United States population will experience low back pain in their lifetime and almost all will have it resolve within a couple of weeks without doing much special. Still, mechanical back pain is the most common cause of disability for those younger than 45 and falls only to number three for those who are older. Almost all are work related, especially for people who use their body as a tool or machine. While a single traumatic event can be the cause of the low back pain, often it is a series of minor traumas that add up to cause the pain. The numerous structures that make up the low back, the bones, ligaments, tendons, discs and nerves, all have to work together to allow the back to function. An injury and subsequent inflammation to any one structure can lead to pain.

The back has many responsibilities including maintaining an erect or upright posture. But perhaps, its most important job is to protect the spinal cord its nerves from damage. Most often the cause of back pain arises from the muscles, tendons and ligaments. The decision point for the care provider is to decide whether the spinal cord or nerves are at risk. If the answer is no, then imaging the back with plain x-rays, CT or MRI is a waste of time, radiation and resources.

Most often, the diagnosis is made by talking to the patient and performing a detailed physical exam. When the pain started is important. Was it acute onset with movement? Or did it arise hours later, perhaps after laying down or getting up in the morning. Understanding the mechanism…was it rotation or torsion of the lower back, or the lumbar spine? or was it flexing or bending forward. That information can help point to what stabilizing structure of the back might be damaged. If the physical exam isn’t exciting and the diagnosis made that it’s all soft tissue (muscle, tendon, ligament), there’s not much to do, except pain control, activity as tolerated and perhaps physical therapy or chiropractic manipulation.

Perhaps the questions that are directed to the potential for nerve impingement or irritation are most important. Is there sharp pain radiating into the buttock or down the leg. Is there numbness or tingling in part of the foot? Nerves that run from the spinal cord can present with pain that follow predictable dermatome patterns and can help determine at what level in the spine damage has occurred. The sciatic nerve is the accumulation of all those nerve roots that supply the leg. Inflammation of any one root can cause significant pain called sciatica. Still, there is little to be gained by x-ray or MRI. The treatment remains pain control and activity as tolerated.

lowerlimbdermatomes

It’s only when signs of impending spinal cord damage does imaging become and urgency. Has the patient lost control of their bowel and perhaps become incontinent of stool? Has he or she lost the ability to empty their bladder and urinate? Is there numbness around the anus or vagina? The questions may seem unrelated to the back but are harbingers of spinal cord disaster and emergent MRI is required.

For most other patients, the best diagnosis and care for low back pain is time and support. Often, symptoms resolve in 2-4 weeks with a combination of rest, ice, heat and anti-inflammatories. Activity as tolerated is always better in mending a back than lying in bed. In some patients, back pain is progressive and further diagnosis and treatment is required, but as opposed to Tony Romo’s x-ray within a few minutes and MRI within 48 hours, the time frame is a lot slower. To be fair, one indication for plain x-rays is in a trauma victim and suspicion of fracture, and being hit by a linebacker qualifies. For most people, however, their trauma is bending over or twisting to pick up a box and that isn’t enough to break bones. (There are always exceptions in medicine and we’ll offer one to little old ladies with osteoporosis who can get compression fractures with little or no trauma).

The stakes are high in the NFL and with player salaries in the millions, there is a want to return the player to the field of play as soon as possible. It causes doctors and trainers yo use technology to bolster their medical opinion. In the real world, the stakes for o every patient are just as high, but it is just as reasonable to trust high touch instead of high tech in caring for their back. If the 85% of the population that will one day experience back pain demand the Tony Romo level of care, unemployment in this country will fall to zero. Somebody will have to build all those MRI machines.

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