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PART IV
ASSESSING AND
TREATING PAIN AND
DYSFUNCTION
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10
Chronic Pain in
Medical Practice
previous chapters have examined the multifac-
eted nature of chronic pain and the complex
interactions among physiological, psychosocial, and psychiatric factors
that contribute to its development and maintenance over time. This
chapter examines chronic pain and chronic pain patients from the
perspective of the physicians who are called on for diagnosis and
treatment. Particular emphasis is placed on the viewpoints of primary
care physicians (who handle about three-fifths of treated back pain
cases) and orthopedists (who handle about one-quarter) (Cypress,
1983).
The focus of this chapter is on the assessment and treatment of pain
in clinical settings, not on the assessment of pain primarily for
certification, although the records from treating physicians may be
used later in disability determinations. In decisions about disability or
about diagnosis and treatment, physicians have similar pressures and
incentives for accurate diagnosis. However, the doctor-patient rela-
tionship in the two settings often differs. In the clinical setting, it is
assumed that the patient has come for an explanation (diagnosis) of
the cause of the pain and for treatment that will relieve it and that the
patient seeks relief. The complaint is usually taken at face value.
These are not necessarily the ground rules of the relationship when the
focus is on certification. Under those circumstances, there is a greater
tendency to challenge the claimant's credibility and motivation in
complaining of pain and disability.
Back pain has been selected as the primary focus of this chapter
189
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190 ASSESSING AND TREATING PAIN AND DYSFUNCTION
because (1) more clinical, epidemiological, and administrative infor-
mation is available on it than for other pain sites; (2) musculoskeletal
pain, especially chronic low back pain, is the most common of the
problematic cases for the disability system; and (3) back pain is
illustrative of many of the clinical issues surrounding the chronic pain
state in general (Drossman, 1982~.
CLINICAL DECISION MAKING
Clinical decision making is a process that unfolds over time. It is
influenced by physicians' training and experience, as well as by
treatment outcomes for individual patients over time. Clinical texts
recommend a particular diagnostic sequence for low back pain that is
usually based on a fairly narrow medical mode] that assumes, implic-
itly or explicitly, that pain complaints can be accounted for by disease
or anatomical abnormalities. However, as will be discussed, most back
pain is not attributable to a particular diagnosis. The initial course of
treatment for back pain is usually targeted directly at symptom relief
If improvement does not result, physicians become more uncertain
about the cause of the complaint and typically expand their inquiries.
Instead of focusing primarily on the symptom, their attention shifts to
the patient with the complaint. Additional observation of the patient
and other diagnostic pursuits are oriented to identifying psychological,
family, workplace, and other social and behavioral factors that may be
affecting the pain. Treatment at this stage may include referrals to
specialists, including mental health professionals, for specific psycho-
social interventions. As discussed throughout this volume, given the
nature of chronic illness generally, and chronic pain specifically, this
broader "biopsychosocial" mode} is likely to uncover important clues to
the etiology and maintenance of the pain complaint that may be
significant for successful treatment and rehabilitation.
The Diagnostic Process
The medical paradigm is relied on to provide the logic for clinical
decision making. A basic premise of the medical mode] is that symp-
toms are the expression of anatomical, physiological, or biochemical
abnormalities indicative of disease. The assumptions on which the
mode} is based help to define the steps clinicians should take in order
to make a medical diagnosis.
In the case of back pain, diagnostic studies are undertaken to
determine specific medical disorders that may account for it, including
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CHRONIC PEN IN MEDICS PRACTICE 191
(1~ acute or chronic low back strain, (2) lumbar disc disease, (3) lumbar
facet arthritis, (4) spinal stenosis, (5) mechanical instability, (6) spinal
infection or tumor, and (7) systemic disease processes or other nonspinal
problems with pain referred to the back. The clinical definitions of these
disorders (e.g., their symptoms, physical signs, laboratory and imaging
findings), delimit the scope of a diagnostic workup. Thus, the patient's
complaint of ''back pain" is explored by a series of clinical acts: (1)
history-taking and (2) physical examination, followed in some cases by (3)
x rays of the lumbar spine, (4) various laboratory tests, and (5) special
imaging of the spinal canal by myelography, computerized axial tomog-
raphy (CAT), and nuclear magnetic resonance (NMR).
1. History-taking. Traditional teaching emphasizes the importance
of a careful medical history focused on the chronic pain complaint as a
symptom of specific back disorders. To illustrate, Wilson and Levine
(1972), writing about history-taking in Arthritis and allied Condi-
tions, advise
a carefully taken history will help greatly to ascertain cause.
A general appraisal should include sex, age, race, economic and social
background, past medical history and a general system review. The type of
work and daily habits are important to ascertain. Relevant points in the family
history should be sought. An analysis of the pain itself is then necessary, and
should proceed along two lines: one concerned with the chronological aspect
. . . the other with the character.
Although the text suggests that demographic characteristics of the
patient should be elicited, the more important dynamic and social
psychological factors in the development of pain are not specified. The
major advice given in this and other texts (Cailliet, 1981) is to eland
the "analysis of the pain itself"- its quality, subjective and sensory
dimensions—namely, "the character" of the pain sensation.
In actual practice, however, medical interviews characteristically are
highly focused and limited to back symptoms along with the other
symptoms of back disorders that may suggest an etiology, such as sciatica
in patients with lumbar disc disease. As a result ofthese narrowly focused
medical interviews, the context of the pain complaint (namely, the
personal situation of the patient in work, career, and personal and family
life) is not regularly elicited. Generally, unless the patient fails to respond
to an initial course of treatment, psychosocial end cultural factors that
may help explain the development of pain or the nature of the patient's
pain report, pain response, and illness behavior are not explored.
2. The Physical Examination. In low back pain, careful physical
examination of the back is advised, including an assessment of back
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192 ASSESSING kD TREATING PEN ED DYSFUNCTION
and joint motions, a neurological examination, as well as observation
of muscle bulk with strength testing and careful palpation of the back
and legs (including muscles, sciatic and femoral nerves). Tension signs
must be tested. The appropriateness and consistency of patient re-
sponses should be carefully observed and nonorganic signs looked for
(Waddell, 19791. The physical examination provides information that x
rays and other tests do not on (1) the degree of functional impairment;
(2) the patient's physical responses as "pain behaviors," such as
posture and limited motion; and (3) the disorder producing the pain,
such as an absent ankle jerk and sensory impairment in the distribu-
tion of the sciatic nerve suggesting nerve root compression (Barr,
1947), or trigger point tenderness suggesting referred or myofascial
pain (Simons and Travell, 19831.
A thorough physical examination can provide valuable diagnostic
information that cannot be obtained in any other way. Yet physicians
often conduct only brief physical examinations and move quickly to
order tests not only for diagnostic purposes but also to satisfy patients'
demands for the latest technology. Tests are also ordered to document
information that may be demanded in malpractice actions, because the
economic incentives are greater for doing tests and procedures than for
interviewing or physical examinations, and because testing procedures
may have some placebo effect in relieving pain symptoms and dysfunc-
tion (Sox et al., 19811.
3. XRays of the lumbar Spine. Films of the Unbar spine are often
the next diagnostic study performed, despite the fact that in 95 percent
of cases they do not provide diagnostic information (Deyo and DiehI,
1986a; Scavone et al., 19811. Even though x rays are of limited value
for diagnosing back pain, it is appropriate to order them to assure that
no relatively rare but very important condition, such as metastatic
tumors and spinal abnormalities, has been overlooked that could be
causing pain. Repeated x rays are generally not appropriate.
4. Laboratory Tests. Blood tests are diagnostic tools that are largely
confirmatory and supplementary indicators of inflammation, infection,
metabolic and neoplastic disease (e.g., the altered immune globulins of
multiple myeloma), or electrolyte imbalances.
5. Special Techniques. When routine, standard x-ray films are
negative, the CAT scan may occasionally localize a ruptured interver-
tebral disc or uncover other important diagnostic considerations such
as spinal stenosis. Among the techniques that sometimes provide
useful diagnostic information are special imaging of the spinal canal
by myelography and NMR, as well as nerve conduction tests, electro-
myography, and thermography.
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CHRONIC PEN IN MEDICS PRACTICE 193
These two to five diagnostic steps are the usual number and sequence
of studies that the physician pursues to define the medical diagnosis of
chronic low back pain (blender, 1981; Mender et al., 19821. These
diagnostic studies oRen uncover one or more of the disorders that are
believed to cause acute low back pain, but the mechanism is rarely
confirmed because that pain is usually self-limited and resolves sponta-
neously (Nachemson, 1976~. In chronic low back pain the diagnostic
explanation is more elusive and only occasionally can be inferred from
these studies and from the outcomes of therapeutic interventions. Indeed,
the predictive power of these examinations and tests (their sensitivity
and specificity) is surprisingly low. A definitive diagnosis con only be
elected in ~10 percent of patients with chronic low back pain (white
and Gordon, 1982; Dodge and Cleve, 19531.
Treatment of the Pain and the Disorder: The Medical Model
In the treatment of chronic Tow back pain by primary care physicians
and specialists, such as orthopedists, neurologists, neurosurgeons,
rheumatologists, physiatrists, and physical therapists, numerous ther-
apeutic modalities have been used (Deyo, 19831:
1. bed rest or restricted activity (Deyo et al., 19861;
2. oral drugs such as analgesics, muscle relaxants, and antidepres-
sants (Fields and Levine, 1984~;
3. exercises;
4. physical therapy with cold, heat, and/or massage (Gibson et al.,
19851;
5. corsets (Coxhead et al., 19811;
6. traction (Coxhead et al., 19811;
7. trigger point injections with local anesthetics; stretch and spray
(Simons and Travell, 1983; Sola, 19851;
8. injections of parenteral and epidural steroids (Urban, 1984)
9. intradiscal chymopapain injection (Smith, 19641;
10. diathermy (Gibson et al., 19851;
11. transcutaneous nerve stimulation;
12. biofeedback and behavioral modification (Fordyce, 1976~; and
13. surgery.
The choice of therapies from this list is likely to vary, depending in
part on physicians' and physical therapists' individual preferences
(Nelson, 19861. The sequence and combination of therapies also vary.
Some are used earlier and others later in the course of chronic pain
when initial treatment fails.
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194 ASSESSING ED TREATING PEN ED DYSFUNCTION
In general, outcomes from these many medical therapies remain
uncertain. In part, these uncertain outcomes may be due to the natural
history of back pain as observed by clinicians, who note that acute low
back pain (or acute exacerbations of chronic Tow back pain) usually
remit in 2 weeks regardless of the mode of treatment (Nachemson,
19761. Thus, time is an important variable in studies of the outcome of
any treatment. Further, few treatments have been tested for efficacy in
double-blind studies (Deyo, 19831. Even if clinical trials were to
demonstrate the benefit of specific treatment modalities, therapeutic
choices would still depend heavily on the individual news of practi-
tioners and their interactions with patients, who themselves have
notions of appropriate treatment regardless of what the doctor recom-
mends.
Despite the variations in choices of specific therapy, the literature
indicates that, initially at least, three therapeutic approaches are most
commonly suggested for the relief of low back pain: analgesics, rest or
restricted activity, and physical therapy (Cypress, 1983; Knapp and
Koch, 1984; Gagnon, 1986; Gilbert et al., 19851. If these interventions
do not pronde relief, then the physician often entertains a second order
of diagnostic questions about the patient's pain complaints and
second order of treatment, which may include surgery.
DIAGNOSING AND MANAGING THE PATIENT WITH PAIN: AN
EXPANDED MODEL
Conventional understandings of disease fail to explain why people
may be disabled by pain in the absence of a disease process that
adequately accounts for the severity of symptoms. Physicians are
trained to identify discrete diseases to the extent possible. They try to
translate the patient's symptom complaint into signs of disease.
Unfortunately, there is not necessarily a one-to-one correspondence,
especially for chronic pain (Cassell, 19851. First, the same symptom
can be caused by many different pathological states. One can experi-
ence back pain, for example, from arthritis, disc disease, muscle strain,
or various kinds of malignancies. Second, a single disease, such as
rheumatoid arthritis, can have widely disparate symptom constelIa-
tions in addition to pain. Third, not only is there not always a strong
correlation between the intensity of symptoms and the severity of
pathology, but extensive pathology may exist in the absence of any
symptoms at all. Hypertension, Jung cancer, and lumbar disc disease
are examples of serious diseases whose pathology may not cause any
symptoms until the disease is quite advanced.
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CHRONIC PEN IN MEDICS PRACTICE 195
When an initial course of treatment has failed, physicians are likely
to expand their inquiries in order to discover "what the patient is like"
(McCormick, 19861. Even if a diagnosis has been identified, if initial
treatment has failed, the diagnosis alone is viewed as insufficient
because it is unable to completely explain the pain or to provide the
basis for practical relief. New clinical questions about the patient (his
or her personality, affect, attributions, previous life events, and cur-
rent stressful situations) have their origins in the physician's diagnos-
tic uncertainty, concern about the patient's behaviors (persistence of
pain complaints and failure to improve with treatment, seemingly low
tolerance for pain, frequent requests for medical help and drugs, and
work absences), and sometimes concern about the authenticity of the
complaint.
These clinical concerns about the patient are not new. Writing about
pain in 1911, Cabot noted
In many cases a strong neurotic element can be traced the mental or nervous
weakness acting on the back through a reduction of muscle tone. Flabby mind,
flabby muscles and unsupported joints, pain. Doubtless any of these factors . . .
may so activate the ache. I do not think anyone knows much about it.
Fortunately, such complete ignorance and uncertainty reflected in
this old text are far less common among practitioners today. Indeed,
the modern clinical literature clearly recognizes the important contri-
butions of psychosocial and situational factors to the etiology and
maintenance of pain, although, as discussed in Chapter 9, distinguish-
ing psychological reactions to pain from primary psychological distur-
bance is often difficult.
At this stage the physician may refer the patient to a specialist in
psychiatry, social work, or clinical psychology for intervention that
may be psychodynamic, psychophysiological, or behavioral. The treat-
ment focus shifts from attempts to relieve the pain directly to trying to
resolve psychosocial issues that may be contributing to the continua-
tion, severity, and disabling effects of the patient's pain. Referrals may
also be made to multidisciplinary pain clinics for a combination of
psychosocial and physical treatment. The value of all these approaches
(psychosocial and physical) in effectively relieving chronic pain has
rarely been demonstrated in controlled studies.
WHY IS THE DIAGNOSIS OF CHRONIC PAIN SO ELUSIVE?
In chronic musculoskeletal pain, such as chronic back pain, proving
the presence of a "name" disease (e.g., a ruptured intervertebral disc)
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196 ASSESSING ED TREATING PEN ED DYSFUNCTION
is seldom possible despite the use of sophisticated diagnostic tech-
niques. This disturbing fact has led to considerable disagreement
among the various specialists concerned with back pain. In addition to
the inadequacies of a narrow medical model, there may be several
other reasons why a diagnosis is not found:
1. the disease or pathophysiological process is as yet unknown—it
has not been identified by medical science;
2. the pain is caused by a disease process that is well known, but the
diagnosis is difficult to establish or has been overlooked; and
3. some physicians believe certain pathophysiological processes
exist and are a cause of pain, but other physicians do not accept the
existence of such processes or do not believe that they explain the pain.
Such controversies over the source of chronic back pain and the
resultant wide divergence of treatment methods cause difficulties for
the insurance industry, Workers' Compensation systems, and the
Social Security Disability program. This divergence is also likely to
confuse the many individual patients whose pain continues unex-
plained, unabated, and ineffectively treated.
Unknown Disease Processes
If the patient has a disease that is, as yet, unrecognized, or one for
which no specific diagnostic test has been developed, it will be
impossible to make a diagnosis. The possibility that patients may be
enduring chronic pain because of deficiencies in medical knowledge
should make clinicians very cautious in disparaging their complaints
or attributing their suffering to purely psychological causes. Even
when chronic pain arises from disease processes that are not under-
stood, it remains possible and necessary to provide adequate pain relief
and to teach the patient how best to carry on despite the pain. In these
circumstances, however, attention to contributory psychosocial factors
may be extremely important in the effective management of pain.
Overlooked Diagnoses
It is unusual but not rare for patients who have been in pain for
prolonged periods to be referred for evaluation to specialized treatment
centers, where they are then found to have diseases that can be
definitively diagnosed and often treated. These diagnoses include
spinal stenosis, tumors, true intervertebral disc disease, infection, and
other diseases that are uncommon causes of back pain. The diagnosis
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CHRONIC PEN IN MEDICS PRACTICE 197
in such patients may have been overlooked because the original
diagnostic evaluation was inadequate or because it took place so early
in the disease process that identification was not possible (see, for
example, Hall et al., 1978; Koranyi, 1979; Ananth, 19843. When
patients have been complaining of pain for a long time, their physi-
cians may become frustrated or impatient with the persistent pain.
When that happens, diagnostic efforts frequently cease and a diagnos-
able disease can be overlooked. As difficult as it may be, such patients
should be repeatedly queried for changes in their symptoms and
examined carefully for changes in their physical findings. As will be
discussed, certain diagnoses such as myofascial trigger points,
fibromyaIgia (fibrositis), and articular dysfunction are considered by
some physicians to be common and remediable sources of pain,
whereas others either do not accept them or are unaware of these
conditions and the manner by which they are diagnosed and treated.
Controversial Diagnoses
The majority of patients with chronic back pain are cared for by
internists or family practitioners whose conceptions of etiology are
similar to those of orthopedics. The traditional understanding of the
field of orthopedics (and neurosurgery) about back pain centers on the
axial skeleton and its associated joint and neurological structures.
There is no question that the pressure on the spinal nerve root that
results when an intervertebral disc (the cartilaginous pad that cush-
ions the space between the vertebrae) ruptures and is extruded from its
proper position can be a consistent and diagnosable cause of leg and
back pain. Further, the pain that occurs in a classical acute rupture of
an intervertebral disc displays a pattern that is explainable by the
anatomy of the bony and nerve structures of the back. In addition, the
pain may be accompanied by other evidence of pressure on the nerve
root, such as loss of sensation or muscle weakness. Surgical removal of
the afflicted disc in such circumstances is often followed by complete
relief of symptoms. In the overwhelming majority of instances of acute
or chronic back pain, however, there is little or no correlation between
the extent of disc disease and the severity of the pain. Furthermore, as
noted previously, only in a small proportion of chronic pain cases is any
clear diagnosis of disease or anatomical abnormality made.
In light of the difficulties in diagnosing and treating back pain
according to traditional models, clinicians have searched for alterna-
tive explanations. Over the past several decades, new views of the
pathogenesis of acute and chronic back pain have arisen that concen-
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200 ASSESSING ED TREATING PEN ED DYSFUNCTION
meanings Mowers, 1904; Reynolds, 1983; Yunus et al., 19821. Some
physicians believe there is considerable overlap between myofascial
syndromes and fibrositis (Simons, 1986) and treat them similarly.
Both are treated with reassurance, physical therapy, and sometimes
with analgesics. Those who are concerned with fibrositis use tender
points to establish the diagnosis without regard to their relation to
muscles. The management of myofascial pain syndromes focuses
specifically on trigger points in muscles and the functions of those
muscles.
Articular Dysfunction
Articular dysfunction that requires mobilization or manipulation for
correction is believed to be another source of acute musculoskeletal
pain that is likely to become chronic if it is not appropriately treated
(Bourdillon, 1983; Dvorak et al., 1985; Lewit, 1985; Maitiand, 1977a,b;
Mennell, 1964~.
IMPROVING DIAGNOSIS, TREATMENT, AND PREVENTION
From this review of physicians' decision making, of their diagnostic
and therapeutic interventions, and of the shortcomings of the tra-
ditional medical approach emerge a number of suggestions for clini-
cal practice that are likely to improve the overall management of
chronic back pain, many of which are applicable to chronic pain
generally.
Diagnosis
Because the development and persistence of chronic pain (including
back pain) and impairment depend so importantly on psychosocial
factors, attention to these factors is essential for diagnosis, treatment,
prevention, and rehabilitation.
Almost all low-back pain has a physical basis [even if it cannot be labeled with
a diagnosis]; psychological ramifications are universal and comnlorlly become
more important after failed or multiple surgery for other treatment], and social
factors may contribute to [impairment], while social consequences of fimpair-
ment] are Unavoidable. Although these three aspects interact and cannot truly be
separated, an approximation of independent assessment is clinically useful. The
aim of the assessment is to evaluate the importance and contribution of each
aspect, their interplay and appropriateness, rather than to search narrowly for
physical, psychological and social disease. (Waddell et al., 1979)
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CHRONIC PEN IN MEDICS PRACTICE 201
A complete history is likely not only to aid in the diagnosis, or at
least an understanding, of the cause of pain, but may also in some
instances provide some pain relief. One study found that patients with
intermittent chronic headaches expressed the greatest relief in those
instances in which a detailed comprehensive history was taken at the
onset of their illness (The Headache Study Group, in press). A careful
explanation of the cause of pain can be reassuring to patients. This
simple cognitive therapy, the explanation of symptoms or illness, is
usually coupled with a placebo effect, such as has also been observed
with diagnostic tests; both may relieve the uncertainty and anxiety
associated with pain (Eisenthal et al., unpublished manuscript).
Second, a comprehensive history early in the course of the pain may
reveal psychosocial or psychiatric problems, which if treated early
could help to avoid chronicit`. Thus, the expanded history would
provide additional clues regarding the diagnosis and the basis for
earlier referral to a mental health professional. Third, even if there are
no mental health problems. a psychosocial history will provide a
broader base for understanding the patient's pain and designing a
treatment plan to address its multifaceted nature.
More attention to history-taking and to physical examination may
make it less necessary to take x rays and to perform other, sometimes
invasive, tests to diagnose chronic back pain. While recognizing that
current reimbursement schemes do not encourage such time-intensive
activities, in the long run they may prove cost effective because they
may uncover clues to the pain that tests do not and point the way to
appropriate treatment.
Treatment of Chronic Pain
It is beyond the scope of this volume to specify treatment protocols in
detail, but two general issues should be highlighted. First, as is true in
medical practice generally, it is most important to treat not only the
disorder but the patient and the symptom of pain as well. An expanded
view of chronic pain that includes attention to psychosocial factors is
likely to result in more effective treatment and prevention. Orienting
medical practice to a more behavioral and preventive mode suggests
some important principles in the care of pain patients:
· Detailed explanation of the cause of pain should be provided to
patients, insofar as the cause is understood, while acknowledging the
attributions of the patient.
· Instruction in medication use should be explicit to assure maxi-
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202 ASSESSING ID TREATING PMN ID DYSFUNCTION
mal control of pain with regular schedules and to avoid overprescrib-
~ng.
· Return visits should be organized to reinforce suggested behav-
iors, provide support, and alter therapy if needed.
· Family members should be involved to help the patient control his
or her pain.
· Collaborative care should be arranged when psychosocial factors
require specific therapeutic interventions. Such referrals occur infre-
quently despite the well-documented frequency of psychosocial impair-
ments in chronic pain patients (Sternbach, 1974) and despite the
promise that such consultations hold for more comprehensive diagno-
sis and complementary psychosocial therapies that could aid in the
treatment of chronic pain. Referral to a mental health professional or
other specialist requires the primary care physician to orchestrate
collaborative care. Coordination can be difficult for the solo practi-
tioner because it requires frequent direct communication with col-
leagues. In multidisciplinary pain clinics and rehabilitation centers,
such collaborative care usually is explicitly organized (see Chapter 121.
The second general issue regards the danger of iatrogenesis in some
of the common treatments used for chronic pain. Three commonly used
treatments for chronic back pain that deserve special comment are the
use of bed rest, medications, and surgery.
Bed Rest and Restricted Activity
The time-honored prescriptions for bed rest and restricted activity
lasting for weeks or months are difficult to rationalize for patients
with nonradiating acute Tow back pain and exacerbations of chronic
low back pain. These patients are usually relieved just as rapidly by
a few days of rest as by much longer periods of inactivity (Deyo
et al., 19861. Clinical efforts should be directed at relieving pain
with mild, nonaddicting analgesics while the patient continues to be
as active as possible. Inappropriate extended periods of inactivity
reduce the effective muscle mass and may make the patient more
vulnerable to subsequent strains. Furthermore, prescriptions for re-
stricted activity may heighten patients' attention to and awareness of
their symptoms and convince them that they are sicker than they
really are. At a certain point, such a view can undermine effort and
motivation and alter social interactions. Thus, there can be physical,
psychological, and social iatrogenic consequences of Tong periods of
inactivity. Most patients with chronic back pain may need to be
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CHRONIC PMN IN MEDICS PRACTICE 203
explicitly counseled that even if their backs hurt, such discomfort is
unlikely to be harmful.
Drug Therapy
Analgesics (narcotic and non-narcotic) and muscle relaxants
(benzodiazepines and non-benzodiazepines) are very commonly pre-
scribed for back pain. In addition, hypnotics may be used to help pain
patients sleep, and antidepressants have recently begun to be pre-
scribed for pain (see Chapter 91. Used in relatively small doses for a
short period of time, these medications can often be effective, either
alone or in conjunction with other therapies. Often, when pain com-
plaints continue, increasingly powerful drugs are prescribed over long
periods of time in increasingly large doses. This is particularly likely
when patients have consulted multiple providers.
There is considerable controversy in the medical community about
the appropriateness of Tong-term drug therapy with opioid analgesics
for nonmalignant chronic pain. Until very recently it was generally
thought that the risks of physical and psychological drug dependence,
drug abuse, increased psychological distress, and impaired cognition
were too great to warrant the extended use of narcotic analgesics for
severe chronic pain (see, for example, Maruta et al., 1979; Maruta and
Swanson, 1981; Medina and Diamond, 1977~. In the last several years,
however, there have been reports indicating that long-term therapy
with these drugs can be successful. For example, Portenoy and Foley
(1986) found that 24 out of 38 patients maintained on opioid analgesics
for at least 4 years for nonmalignant chronic pain achieved "acceptable
or fully adequate relief of pain." Few patients required escalating
doses, management was a problem for only two patients (both of whom
had a history of drug abuse), and toxicity was not a problem.
Clearly, drug therapy is an unportant element in the treatment of
chronic pain, either alone on in conjunction with other modalities.
Regardless of the type of drug prescribed or the duration of drug
treatment, physicians need to be alert to the possible unintended, often
adverse, side effects of drugs, including physical and psychological depen-
dence, impaired motor coordination, altered daytime functioning, and
symptoms of withdrawal when medication is discontinued. For example,
symptoms of benzodiazep~ne withdrawal may not begin until several days
after discontinuation of the medicine and therefore may not be recognized
as abstinence reactions by either the patient or his or her physicians
(Greenblatt et al., 1983; Schopf, 19831. More careful monitoring of the
effects of medications may prevent unnecessary iatrogenic complications.
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204 ASSESSING kD TREATING PMN ED DYSFUNCTION
Surgical Treatment
Although surgical treatment can be dramatically helpful for a high
percentage of patients with acute sciatica due to a herniated lumbar
disc, resulting in prompt and effective relief of leg pain in at least 95
percent of them, not all patients with lumbar disc rupture require
surgery. Even when an extruded lumbar disc is suspected, analgesics
and a period of rest are indicated unless a major, progressive neuro-
logical deficit develops. Even when surgery is elective in relieving
sciatica, comparisons of surgical and nonsurgical treatments reveal no
differences in outcomes after 2 years (Weber, 1983~.
Surgical treatment for chronic Tow back pain is less often effective
than in acute sciatica, and rarely produces dramatic relief of back or
leg symptoms except in problems of spinal stenosis, or in unusual
abnormalities due to tumor or infection. Problems of spinal stenosis
are becoming increasingly recognized and are amenable to surgical
treatment in the majority of patients whose condition is confirmed by
myelography, computerized body tomography, and magnetic reso-
nance imaging. Infection, tumor, and spinal instability problems may
all result in chronic back pain; and although these conditions are
relatively uncommon, surgical treatment remains a definitive man-
agement. Of concern are those conditions in which the pathology
demonstrated is not a clear cause for chronic low back pain, in which
case surgical treatment should not be considered.
Numerous research studies and clinical observations reported in the
literature indicate that surgery for chronic back pain is overused and
often misused, that it is seldom any more effective than nonsurgical
treatment in either the short or long term and often is less effective,
and that back surgery (especially repeated surgery) frequently results
in serious iatrogenesis. "With successive low-back operations, the
results rapidly deteriorate . . . beyond two operations, further surgery
was more likely to make the patient worse rather than better"
(Waddell et al., 19791. Generally, after one unsuccessful back opera-
tion the chances of rehabilitation are significantly reduced, and after
two or more failed operations it is very unlikely that operative
treatment will be of value. An important exception to this general
statement is when evidence is uncovered suggesting that the initial
operation was not effectively designed or executed to address the
known pathology. In such cases, additional surgery may be warranted
and effective.
In cases of chronic intractable disabling pain in which the specific
etiology cannot be determined or treated, neurosurgical procedures for
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CHRONIC PEN IN MEDIC^ PRACTICE 205
pain relief are helpful for a few select patients. For patients with
disabling pain after failed lumbar surgery, dorsal column stimulation
or focal installation of spinal morphine may, in a very few cases, offer
a temporary period of pain control during which some of these patients
can become functional. In most medical centers, other neurosurgical
operations, such as cordotomy, extensive rhizotomies, or midline
myelotomy are no longer used in rehabilitative efforts for the patient
disabled by chronic pain of nonmalignant origin.
In a study of work disability in newly diagnosed cases of arthritis,
people who underwent surgery were less likely than others to continue
working (Yelin et al., 1980~. In fact, cessation of employment was
predicted twice as well by having had surgery as by physicians'
judgments of the initial severity of the illness. Moreover, for each
therapy and drug regimen commonly prescribed by physicians for
patients with arthritis, stopping work became more likely (but to a
lesser degree than for surgery). Although it is possible that the need
for therapy indicated severity of disease more sensitively than the
physicians' reported judgment, it is also possible that in addition to
providing some relief from pain, medical therapies may also have
served to reinforce a lifestyle of invalidism. Thus, an important
preventive measure to avoid iatrogenesis and mitigate long-term
disability is to refrain from back surgery unless there is a clearly
identified, surgically correctable problem and reasonable conservative
treatment has failed.
RECOMMENDATIONS FOR CLINICAL RESEARCH
This overview of how chronic pain is handled in clinical practice
highlights a number of areas in which current practice appears to be
inadequate (and perhaps harmfill), and in which the rationale for physi-
ciar~s' behavior is based more on medical tradition than on the demon-
strated efficacy of particular techniques or strategies. Pain, like insomnia
and functional bowel distress, is a symptom complaint that has been
relatively neglected in medical education and clinical research despite
the fact that it is a common problem. In recent years there has been an
increased interest in the multifaceted clinical aspects of chronic pain, but
much research remains to be done. There are three broad questions for
which clinical research would be particularly useful:
1. For what types of patients and in what circumstances does acute
pain progress to chronic disabling pain, and can these patients at risk
be identified early?
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206 ASSESSING ED TREATING PEN ED DYSFUNCTION
2. What specific treatment modalities are effective for which pa-
tients, and how do particular aspects of the doctor-patient relationship
influence the effectiveness of treatment?
3. What are the optimal times in the pain-disability course for
particular kinds of interventions?
As discussed in Chapter 6, less than 10 percent of people with acute
back pain develop chronic disabling pain. If those people who are at
risk for long-term illness and impairment could be identified early, it
might be possible to design more effective treatment plans that could
prevent long-term chronicity for at least some patients. At this time
certain factors are known to be correlated with Tong-term problems,
but they are not useful as predictive factors. More detailed patient
topologies and classifications based on the development of chronic pain
and disability are needed.
There is a paucity of data in the literature about the effectiveness of
diagnostic tools (including the history-taking interview and physical
examinations and treatment modalities for pain. The Quebec Task
Force on Spinal Disorders (Spitzer and Task Force, 1986) concluded
that methods of treating chronic pain are, by and large, untested in
well-controlled clinical trials. Few treatments have been shown to
improve the natural history of nonspecific spinal disorders. Clearly,
there is a need to assess interventions in order to see what works alone
or in combination and for which kinds of patients.
Among the treatments that should be evaluated are some of the
alternative care therapies offered by chiropractors, holistic health care
practitioners, and others that were discussed in Chapter 8. A number
of questions could usefully be addressed: Do these therapies actually
alleviate pain or do they alter pain perceptions or attributions so that
disability is avoided despite persistent pain? Do particular forms of
heating techniques preclude or interfere with medical treatment, or do
they complement medical care by taking account of important psycho-
social factors sometimes neglected in current medical practice? Are
particular therapies elective only with individuals with certain group
affiliations or personal characteristics? Do certain alternative thera-
pies have potentially harmful erects that may exacerbate pain and
disability? If, as a few studies suggest, outcomes depend on the
characteristics of the provider more than on the actual techniques
used, such findings may point the way to specific alterations in
physician behavior or in the doctor-patient relationship that will
promote rehabilitation and recovery.
Finally, there is a very critical question about the optimal timing of
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CHRONIC PAIN IN MEDICAL PRACTICE 207
interventions. Intuitively it makes sense to suggest that early atten-
t~on to psychosocial problems might alter subsequent illness behaviors
and mitigate the long-term negative consequences of pain. However,
this has not been adequately tested. Generally, clinicians agree that
the longer people have been impaired, the harder it is to treat or
rehabilitate them (see Chapter 121. What is not known is whether
early interventions and rehabilitation efforts prevent later problems.
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Representative terms from entire chapter:
myofascial pain
