Tuesday, February 14, 2017

Damping Down Fear about Back Pain

By some ways of looking at the problem, back pain is a crisis in America. There are millions of sufferers, and some of them have had to stop working because of debilitating pain. Back pain is one of the most common reasons doctors prescribe opiate painkillers, which have become a crisis of their own.

But all of this is really rather puzzling. Many people with back pain have no obvious injuries that show up on an MRI, while MRIs of some pain-free people show what look like serious problems. Problems like extruded disks that used to get you whisked into surgery are now known to be common in healthy people. Big studies of surgery for spinal disk issues show that on average it is no better than a week in bed and some physical therapy. On the other hand I know two people who swear up and down that back surgery transformed their lives, and there are many thousands of such people in America.

So I never know what to make of all this. But I feel sure that one of the biggest problems with back pain is that it is scary. Partly this is physical, because it hurts and feels fundamental in a way that an injured hand or foot does not. It can make your legs go so stiff or wobbly that it is like a pseudo paralysis. Plus there is the background noise, all the people around us crippled by it.

New guidelines from the American College of Physicians recognize the importance of fear in back pain patients:
The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief.

Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said.

In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.

“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”
We are witnessing a major move away from heroic medicine. Many kinds of surgery are falling out of favor – cardiac bypass, arthroscopic surgery for knee cartilage tears, back surgery for extruded disks – because studies have shown that on average they do little good. Drugs introduced with great fanfare now seem to be only a little better than placebos. Maybe, just maybe, we are acquiring a little medical wisdom, and we will start to cut back on expensive medicine that does little good to focus on what we can achieve.

5 comments:

Michael said...

I had back pain due to a severely herniated disc. It was usually tolerable and would get better/worse over time. In 1993 it went REALLY bad - the pain was blinding. When I awoke following a 1.5 hour surgery, the pain was gone, numbness in my leg and toes was gone, and has been 100% since. I asked the surgeon why this was so "easy." He said, 1) you are not overweight, and 2) you exercise regularly.

G. Verloren said...

1/2

But all of this is really rather puzzling. Many people with back pain have no obvious injuries that show up on an MRI, while MRIs of some pain-free people show what look like serious problems. Problems like extruded disks that used to get you whisked into surgery are now known to be common in healthy people. Big studies of surgery for spinal disk issues show that on average it is no better than a week in bed and some physical therapy. On the other hand I know two people who swear up and down that back surgery transformed their lives, and there are many thousands of such people in America.

So I never know what to make of all this.


I would assume the source of the discrepancy isn't based so much in how much raw damage your back has suffered, but rather is based more in your neurological and psychological response to whatever damage there is. Different people simply experience pain differently.

On the physical side of the issue, if your nervous system is simply tuned to be more sensitive than someone else's, then a condition that causes only minor discomfort for them could cause crippling pain for you.

Compare to things like allergies, or alcohol and drug tolerances, or tolerance for hot spices. Some people have genes that enable to them to walk through a field of blooming spring flowers and breath freely and deeply, while other people have genes that cause their immune systems to freak out and try to violently purge the pollen through fits of hacking, coughing, and sneezing. Some people have genes that let them drink a six pack of beer and hardly feel it, while other people have genes that leave them tipsy after a single glass. Some people can eat spicy peppers with barely any reaction, while other people suffer intense agony from merely gettings capsaicin on their skin, much less in sensitive regions like their mouths and throats.

But then in addition to your relative physical sensitivity to something, there's also a strong psychological element. You can acclimate to incredible sources of pain if you have the proper motivation, and at the same time you can be hyper sensitive to the most minor of injuries because of some psychological trauma you associate with them.

I used to know a professional boxer and mixed martial artist who was so used to be being pummeled and cut up in the ring that he barely even felt it anymore, but he simple could not handle going to the doctor and getting a flu shot because of an unresolved childhood phobia. You could hit him over the back with a sledgehammer and he'd walk it off, but the moment a tiny little needle drew a single drop of blood he was screaming in completely genuine pain and misery, tears streaming down his face, all composure thrown straight out the window.

G. Verloren said...

2/2

So to me it makes perfect sense that one person with a nearly undamaged back might be sent howling at the slightest problem, while another person whose back looks like it eat a fragmentation grenade doesn't even notice. I'd argue it depends entirely on the individual's physical sensitivities, in turn amplified by their psychological complications.

There are people who have been shot in the head and never even realized, only discovering the fact decades later when doctors gave them MRIs for unrelated issues. And there are people who get rushed to hospitals in genuine agony after a terrible accident, only to have the doctors discover they're perfectly unharmed, and as soon as they realize that fact the pain disappears.

You can "burn" yourself by touching a cold stove that you've convinced yourself is hot. You can make people feel genuine pain by creating a visual illusion that tricks the brain into thinking a fake arm on a table is actually their arm, and then poking it with a sharp object.

There's a newly developed therapy for amputees who suffer phantom "pain" and "paralysis" in their missing limbs, that involves using a mirror in a box to reflect the remaining limb into the appropriate space, and then flexing and stretching it, which over time causes the brain to have the sensation of the pain subsiding and the paralysis disappearing - and in some cases, eliminates any sensation of a phantom limb entirely.

There's a man who spent most of a year trying to learn how to ride a bicycle which had been modified to have the steering inverted, and failed miserably over and over until one day, suddenly something clicked, his brain "rewired" itself, and it was as if he had been riding the backwards bicycle all his life - with the side effect that he could no longer ride a normal bicycle properly.

The human brain and nervous system is absolutely amazing and insanely complicated - which is precisely why treating back pain is so difficult and unintuitive. But one things seems clear - drugs aren't the solution. We need to explore more deeply into the possibilities of physical and psychological therapy.

David said...

We may be moving away from "heroic" medicine as the default solution, but I wouldn't want to see an abandonment of procedures that have clearly worked for some people. The solution surely is to find out why back surgery works for some and not others, and look for a way to better identify the patients who are most likely to benefit from surgery.

John said...

@David -- that would be the best solution, but it's very hard to implement. There has been a lot of talk about genetic medicine and personalized medicine, driven by concerns like these and by the very different responses some people have to drugs. But we are a very long way from understanding why what works on one person makes another worse.