Sunday, July 29, 2018

Back Pain

I complain often here about the stupidities of our medical system, and lately we have seen much trouble and some major retractions in the fields of sociology and social psychology. But sometimes the system works. Consider this review of studies on back pain. Back pain is the single biggest reason people miss time at work and the leading reason why working people seek disability payments, and we are really bad at treating it. Or, to be more precise, we are really bad at treating "chronic, nonspecific lower back pain," the kind that mainly disables people; most back pain is treatable with ibuprofen and a few days of rest.
Historically, the medical community thought back pain (and pain in general) was correlated to the nature and severity of an injury or anatomical issue. But now it’s clear that what’s going on in your brain matters too.

“Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role but psychological and social factors also play a big role," Roger Chou, a back pain expert and professor at Oregon Health and Science University, summarized.

When you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.

The awareness about the role psychological factors play in how people experience pain has grown more widespread with the general shift away from the dualist view of the mind and body toward the more integrated biopsychosocial model. Chronic nonspecific low back pain “should not been considered as a homogenous condition meaning all cases are identical,” researchers in one review of the research on exercise cautioned.
In response to a flood of studies showing that surgery has highly uneven results, opiates mostly work no better in the long run than aspirin and also kill people, and steroid injections provide only short-term relief, doctors are becoming much less likely to recommend radical measures and much more likely to refer people for some combination of psychiatric counseling and physical therapy.
Most recently, in February 2017, the American College of Physicians advised doctors and patients try “non-drug therapies” such as exercise, acupuncture, tai chi, yoga, and even chiropractics, and avoid prescription drugs or surgical options wherever possible. (If the non-drug therapies fail, they recommended nonsteroidal anti-inflammatory drugs as a first-line therapy, or tramadol or duloxetine only as a second-line therapy.) In March 2016, the Centers for Disease Control and Prevention also came out with new guidelines urging health care providers to turn to non-drug options and non-opioid painkillers before considering opioids.
Which is not to say that tai chi is a miracle cure for back pain; these alternative approaches are also hit or miss. But compared to surgery or opiates they are really cheap and much less likely to do long-term harm. Since they do help many people, why not try them? Increasingly doctors agree.

All of this, I think, points toward the great power of the analytical tools we have for studying our society and our bodies. Back surgery, for example, seems to work very well for a few people – I have two friends who swear they were cured from decades of pain by a single surgery – and many doctors kept doing it because of those success stories. To understand how rare these miracle cures are we had to track thousands of cases and analyze them in terms of many variables. This still has not enabled us to predict who will be cured and who will not, but it has helped doctors formulate the problem better.

Even more important has been the sociological data. The fact that people who have recently lost a job or gotten divorced are much more likely to be disabled by back pain tells you something important about the problem, and it is only massive statistical studies that have forced people to confront this reality. Without this mass of data people advancing the "biophychosocial" model would be accused of elitist scorn for poor injured working people, and the whole thing would have become yet another unresolvable political mess. But the data, from dozens of studies of millions of people, is simply irrefutable.

Through statistical analysis we have come to understand this problem much better, and the new medical approach – which amounts to trying different things until something works, with surgery as a last resort – seems to be working much better than what we did before.

On the other hand, through sociology and statistics we have come to understand that rather than being a simple medical problem of the kind we are good at solving, back pain is a social, psychological, and spiritual problem of the kind we are very bad at solving. What many people disabled by back pain really need is better lives: more friends, stronger communities, more meaningful work, less loneliness, less stress. But I would still say that yoga, tai chi, exercise, and therapy are more likely to help with that fundamental issue than surgery.

1 comment:

David said...

To me, everything you say here makes good sense. Among other things, you make a persuasive case for the value of statistics, and demonstrate how they can be used to enlighten while it remains that humans, appreciating the complexity and individuality of each case, actually set policy and make decisions, with saving money as a consideration, but not the defining one.

What is needed is extremely granular, sophisticated decision-making with multiple axes of consideration.