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PART IV ASSESSING AND TREATING PAIN AND DYSFUNCTION
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
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
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 dimensionsnamely, "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
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.
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.
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.
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)
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 unknownit 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
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-
198 ASSESSING ED TREATING PEN ED DYSFUNCTION bate on back structures other than the axial skeleton. One such understanding, held by increasing numbers of specialists in rehabili- tation medicine, is based on the view that myofascial trigger points and referred muscular pain (myofascial pain syndrome) are a major cause of pain. In this view, the primary difficulty in chronic back pain lies in the muscles, not in the axial skeleton or associated joints; muscular dysfunction is believed to frequently play an essential part in chronic back pain even when disc disease is present. Some clinicians agree with this view and others disagree. Indeed, the study committee's discussion of this topic was very heated. Al- though all the clinicians acknowledged the existence of muscular involvement In back pain, some expressed strong doubts about the existence of myofascia] trigger points. Similarly, others expressed strong doubts that the orthopedic view of the pathogenesis of back pain is correct. Although advocates of the view that trigger points and referred pain are primary elements in the pathogenesis of many common pain symptoms acknowledged the absence of controlled clin- ical trials for this (and most other interventions for back pain), they pointed to a rapidly growing literature reporting that the diagnosis is useful and common (Fishba~n et al., 1986; Fricton et al., 1985b; Skootsky, 1986) and asserted that efficacious treatment approaches have been developed. The committee did not reach agreement on this. Because of the debate and in light of the increasing prominence of myofascia] pain syndrome in clinical reports, the committee believed that the topic- and the controversy should be brought to the attention of clinicians and researchers. Myofascial Trigger Point Syndromes* Proponents believe that trigger points develop in the following way: Because the muscles are not stretched through their normal range of motion (from misuse, lack of exercise, mechanical overload, or recur- rent minor injury), they shorten. During subsequent muscular activity at work or while exercising, the muscles are repeatedly strained, which may induce further shortening. It is believed that trigger points are produced in the strained and repeatedly injured muscles. Trigger points that arise in these acutely injured muscles usually become latent trigger points after a few days of rest and protection of the * For a more detailed discussion, see the Appendix.
CHRONIC PEN IN MEDlC~ PRACTICE 199 muscle from mechanical overload. Those who consider that myofascial syndromes are a common source of chronic back pain suggest that alternation between the active and latent status of the trigger point is the usual basis of recurrent or chronic musculoskeletal pain problems (Travel! and Simons, 19831. In the presence of perpetuating factors (mechanical or systemic), an acute myofascial trigger point syndrome is likely to persist and become chronic despite appropriate therapy (Simons, 19851. Specific myofascial therapy includes a variety of techniques whose object is to restore the muscle to its normal length and pattern of action and to inactivate the trigger points (Travel! and Simons, 1983; Sola, 1985; Lewit and Simons, 19843. Trigger points, which may develop in any of the approximately 500 skeletal muscles, have five cardinal features that distinguish them from other musculoskeletal disorders (Travel! and Simons, 1983; Simons and Travell, 19841: 1. The history of the pain is muscle oriented; the pain consistently relates to the positioning or use of specific muscles. 2. There is reproducible, exquisite spot tenderness in the muscle at the trigger point. 3. There is pain that is referred locally or at a distance on stimula- tion of the trigger point either mechanically or by a needle. This referred pain and tenderness is projected in a pattern characteristic of that muscle and reproduces part of the patient's complaint. Patterns of referred pain are frequently different than those expected on the basis of nerve root innervation (Travel! and Rinzler, 1952; Travell, 19761. 4. There is palpable hardening of a taut band of muscle fibers passing through the tender spot in a shortened muscle (Simons, 19761. 5. There is a local twitch response of the taut band of muscle when the trigger point is stimulated by snapping palpation or needle penetration (Fricton et al., 1985a). Fibrositis or FibromyaZgia Many rheumatologists and some other physicians who treat chronic muscuToskeletal pain consider fibrositis (or fibromyaigia) to be a frequently overlooked source of chronic pain (Wolfe and Cathey, 1983; Bennett, 1981; Campbell et al., 1983; Yunus et al., 19821. The fre- quency with which fibrositis (or fibromyaIgia) is diagnosed suggests that a specific entity is being described (Smythe and Moldowsky, 1977; Smythe, 1985; Bennett, 1981, 1986; Wolfe and Cathey, 1983; Yunus et al., 1982), but these terms have a checkered history of multiple
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)
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-
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
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.
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
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?
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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