Every day, a whole lot of people develop back pain. I don’t mean the old achey breaky back from doing the garden, I mean mean ole back pain that grabs and holds on and sends stabbing through your butt and down your leg. What would you do if it were you?
Depending on the doctor you consult, you may be given conservative management and little else – by conservative I mean you might get some good pain relief, a referral for mobilisation by physiotherapy or osteo/chiropractic, and lots of reassurance. Or you may be recommended a range of injection therapies – some of them diagnostic, some of them designed to reduce pain. Or you may even be referred to an orthopaedic surgeon or neurosurgeon. Which one is the best? What does the evidence say?
One doctor I know suggests that ‘medicine has advanced to the stage of diagnosis of the vast majority of cases of lower back and neck pain; the technology is not available everywhere but there are evidence-based methods for identifying the source of most cases of chronic spinal pain’…He said to me that he finds it very hard to understand why patients are sent to interdisciplinary pain management when they could be referred for diagnostic blocks that ‘might and in the majority of cases almost certainly will, lead to specific treatment with the potential to reduce or abolish the pain and allow the patient to resume normal activities including work with their self-image and other psychological aspects of personality intact.’
Well, to help sort out some of the dilemmas that we face as patients and therapists, guidelines, or consensus statements, or even evidence-based reviews are published. These represent a synthesis of the relevant scientific literature available, and yes they do represent opinions about the level of evidence and which recommendations should be made in preference to others – and they are positions made in time, and often reviewable. Nonetheless, they often summarise the state of play and can help us determine ‘the next best step’ to take for patients.
I was interested to read the American Pain Society Clinical Practice Guideline for low back pain. The stated aim of this guideline is to ‘develop evidence-based recommendations on use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation for low back pain of any duration, with or without leg pain.’
I won’t review all the recommendations, but two things stood out particularly for me.
The first is the recommendation not to use diagnostic blocks or provocative discography to diagnose discogenic low back pain. The determination regarding discography is strongly recommended with moderate evidence, while the recommendation not to use diagnostic blocks is based on insufficient evidence. Clearly this can change over time, but currently, even with a positive discographic finding, ‘there is no evidence that use of provocative discography to select patients for fusion improves clinical outcomes’. The authors state ‘No reliable data exist on the diagnostic accuracy or clinical utility of diagnostic facet joint, medial branch, sacroiliac joint, or selective nerve root blocks.’ and go on to indicate that in part because of the lack of diagnostic accuracy, and in part because there is no way to use those findings to guide treatment, there is no reliable way to determine whether they should be used. Hmmmm.
My reservations about diagnostic blocks and so on are:
- the time it takes to proceed through the placebo controlled series of injections,
- the cost of these procedures, and the
- lack of definitive treatment – especially the lack of long-term treatment – that can be given even if ‘the source of the nociception’ can be found
- the emotional and functional cost of delaying reactivation ‘until the pain source is found’
The second finding that really piqued my interest is the second quite strongly-given recommendation that ‘patients with nonradicular low back pain who do not respond to usual, noninterdisciplinary interventions, it is recommended that clinicians consider intensive interdisciplinary rehabilitation with a cognitive/behavioral emphasis (strong recommendation, high-quality evidence).’
- Two points here – this recommendation is given as a positive rather than ‘if everything else fails’ which suggests pain management should not be the ‘last resort’ for patients (don’t wait until they’ve lost hope of living a normal life’.
- The second is that the findings suggest ‘the most effective programs generally involve cognitive/behavioral and supervised exercise components with at least several sessions a week, with over 100 total hours of treatment.’
This is not a programme to be undertaken ‘if time permits’, or ‘when I’m not doing other things’ – this is just as significant a commitment as undergoing surgery.
I’m curious to find out who will come out against these recommendations – people with a vested interested in using interventional treatments? People who believe that psychosocial and behavioural factors are secondary to experiencing pain? People who would prefer to think a quick fix to abolish pain is the best way to help someone regain a life, even when the ‘quick fix’ may be helpful in the short-term only?
I look forward to the day when my medical colleagues will look to interdisciplinary pain management not as a ‘last resort’, but as the best approach to helping people retain dignity, return to a positive outlook, and enjoy their future.
Roger Chou, MD, John D. Loeser, MD, Douglas K. Owens, MD, MS, Richard W. Rosenquist, MD, Steven J. Atlas, MD, MPH, Jamie Baisden, MD, FACS,Eugene J. Carragee, MD,Martin Grabois, MD, Donald R. Murphy, DC, DACAN, Daniel K. Resnick, MD, Steven P. Stanos, DO,William O. Shaffer, MD, and, & Eric M. Wall, MD, MPH,For the American Pain Society Low Back Pain Guideline Panel (2009). Interventional Therapies, Surgery, and Interdisciplinary
Rehabilitation for Low Back Pain
An Evidence-Based Clinical Practice Guideline From the American
Pain Society Spine, 34 (10), 1066-1077