Pain and Disability Clinical, Behavioral, and Public Policy Perspectives (1987) / Chapter Skim
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10. Chronic Pain in Medical Practice
10. Chronic Pain in Medical Practice
Pages 187-210
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From page 189... ...
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)
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From page 190... ...
Treatment at this stage may include referrals to specialists, including mental health professionals, for specific psychosocial 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.
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From page 191... ...
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.
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From page 192... ...
When routine, standard x-ray films are negative, the CAT scan may occasionally localize a ruptured intervertebral 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, electromyography, and thermography.
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From page 193... ...
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 therapeutic modalities have been used (Deyo, 19831: 1. bed rest or restricted activity (Deyo et al., 19861; 2.
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From page 194... ...
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.
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From page 195... ...
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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From page 196... ...
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.
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From page 197... ...
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 cushions the space between the vertebrae)
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From page 198... ...
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 clinical trials for this (and most other interventions for back pain)
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From page 199... ...
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)
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From page 200... ...
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 traditional medical approach emerge a number of suggestions for clinical practice that are likely to improve the overall management of chronic back pain, many of which are applicable to chronic pain generally.
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From page 201... ...
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.
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From page 202... ...
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.
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From page 203... ...
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.
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From page 204... ...
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.
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From page 205... ...
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)
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From page 206... ...
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 psychosocial factors sometimes neglected in current medical practice?
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From page 207... ...
Barr, J.S. Ruptured intervertebral disc and sciatic pain.
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From page 208... ...
Myofascial pain syndrome: electromyographic changes associated with local twitch response. Archives of Physical Medicine and Rehabilitation 66:314-317, 1985a.
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From page 209... ...
Simons, D.G., and Travell, J.G. Myofascial pain syndromes.
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From page 210... ...
Failed lumbar disc surgery and repeat surgery following industrial injuries. Journal of Bone and Joint Surgery 61:201-207, 1979.
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