Chronic Back Disability's Confusion-Frustration-Risk
Confusion of Chronic Back Disability
The potential for confusion warns us about chasing the cause of pain in all medical and surgical approaches to patient care. Potential mistakes are especially great in the small subset of back patients whose limitations linger the longest. These slow responders to back care seem significantly different than the average patient with acute symptoms or one chronically bothered by chronic symptoms but not chronically disabled. In the absence of major trauma or serious structural disease (tumor, infection, gross instability) non-physical issues (psychosocial issues, high co-morbidity of other chronic pain processes, mental health problems) have especially been correlated to the slowest back patients to recover reasonable activity tolerance (Bigos et al.`91, Klenerman et al.`95, Valat et al.`97,Burton et al.`95, Burton et al.`97, Carragee et al.`01, Linton et al.`00, Pincus et al.`02, Boersma et al.`05, Carragee et al.,`06, Brage et al.`07). Poor conditioning and poor general health and early death are what we see in those disabled by back symptoms (Biering-Sorensen et al.`99, Ross`95, Gerdtham & Johannesson`03).
Some have associated chronic low back disability with disk degeneration, (Ito et al.,`98) annular disruption,(Ito et al.`98, Aprill et al.`92, Carragee et al.,`00) end-plate changes (Weishaupt et al.`01). But imaging studies using MRI in asymptomatic subjects (Boden et al.`90, Jensen et al.`94) indicate how improbable these findings are of clinical significance on a case by case basis except for a few findings* when extreme. Normal findings on MRIs in subjects without symptoms are as high as 70% for Degeneration increasing with age, 33% for Annular fissure bright signal, 18% for Extrusion, 10% for Vertebral end plates signal changes, and 50% for Herniation*. (See Normal imaging findings)
From where does the disabling pain come? Our limited physical knowledge helps explain why 70-80%of chronically disabled patients are found to have psychological distressed on psychometric testing or prior compensation dispute and at most only 20-30% have hints of definite pathologic or destructive processes on imaging studies (Cairns et al.`03, Carragee et al.`01). Pain studies find chronically disabled back patients to have an exaggerated response to noxious stimuli than normal controls (Giesecke et al.`04)*** and anticipation of pain reduction alters in signals of their brain's prefrontal cortex on functional MRI (Wager et al.`04). The chronically disabled also have been found to have dysfunctional coping strategies that mirror cerebral spinal fluid increases of substance P and Nerve Growth Factors with lower endorphins and possibly hyperactive spinal cord N-methyl-D-aspartate (Giesecke et al.`04, Wager et al.`04, Onda et al.`05, Peng et al.`05). Chemical issues may help explain why nerves can be mechanically irritated more easily at one time period and not at others. Clinical evidence indicates pain sensitivity can be increased by prematurity, rape, harassement, chronic persuasion, nocebo that has to date provided few clues to a reasonable clinical approach.
A myriad of non-physical issues seem to complicate our treatment chronic back disability but also our ability to study it. Intervention studies in chronic problems are commonly marred by placebo effect (Kaptchuk et al.`00). A few of the more dramatic proven placebo effects include internal mammary artery implant for angina, inner ear surgery for tinnitus, lavage for knee pain, and implant of dopamine neurons for Parkinson. The Placebo effect seems to complicated studies more in these chronic disability than more acute counterparts. Conversely, our strategies are yet to be significantly altered by knowing pain sensitivity is decreased by various pain killers, joy, happiness and placebo effect of drugs, injections, surgery.
As in the acute setting, patients should understand that imaging is to rule out serious conditions, and to expect degenerative findings. Over-use of imaging studies risks especially in chronic patients reinforces the suspicion of serious disease, magnifying the importance of nonspecific findings, and labeling patients with spurious confusing diagnoses (Carragee`05, Bigos et al.US Dept Health HS AHCPR `94) Thus, in our present state of confusion caring for the patient far outweighs the potential of even the least risky treatment methods in meeting the needs of the chronically disabled patients.
Conservative Care for Back Disability Treatment is fraught with frustration
Studies concerning treatment of chronically disabled patients are not very compelling. Clinical significance is difficult to discern when placebo is compared to analgesics (Ostelo et al.`05), anti-inflammatory (vanTulder et al.`00, Coats et al.`04, Nussmeier et al.`05), muscle relaxants in randomized trials (vanTulder et al.`03). Side effects of narcotic & sedative discourage long term use (Ostelo et al.`05) and no clear advantage can be found for use of physical therapy, massage, manipulation, low-impact aerobics, exercise with or without training machines, or back school in the chronically disabled back patient.(Mannion et al.`99, Hurwitz et al.`02, Assendelft et al.`03, Cherkin et al.`03) in getting rid or the pain and fostering productivity.
Combining medical care with (physical therapy [Hurwitz et al.`02] or manipulation [Niemisto et al.`03]) is possibly more effective in reducing pain & self-rated disability in chronically disabled patients than single methods alone. One must wonder if it may only reflect an increase in the patientís confidence with multiple providers being on the same page of the hymnal (Hurwitz et al.`02, Deyo et al.`03, Goldstein et al.`02). Functional Restoration with cognitive behavioral focuses on specific functional goals seem to have the edge over usual care by a general practitioner relative to sick leave for a while (van Tulder et al.`01, Guzman et al.`02, Ivar Brox et al.03, Schonstein et al.`03, Fairbank et al.05) but its sustainable long term effect is questionable (Ostelo et al.`05). Importantly, pain management programs focusing on finding the pathology causing the pain, relying spinal injections and analgesic drugs show NO BETTER functional outcomes than USUAL CARE (Guzman et al.`02).
Various types of exercise seem equivalent in impact on the chronic low back patient but are more effective in increasing return to normal activities than usual care of general practitioner (van Tulder et al.`00). A one-hr session 2-3 times per week for 4-6 weeks or until resuming normal activities was found to reduce pain on 100 point VAS by 10-15 points and improve functional scale Improvement 5-10% (van Tulder et al.`00, Staal et al.`04).
Invasive Procedures for Back Disability Treatment is fraught with Risk
Injections seem least risky but if there is NO radiculopathy there should be NO epidural Injections. Epidural Steroids or analgesics are not indicated for Back Pain alone and at best questionable for radiculopathy (Nelemans et al.`01). Justification does NOT presently exists for injections of lumbar disks, lumbar facets, and trigger points (Carette et al.`91, Nelemans et al.`01, Khot et al.`04) NOR for sclerosing agents injected into the lumbar fascia.(Dechow et al.`99, Yelland et al.`04). Recent randomized trials indicate no clinical or statistical effect (Barendse et al.`01, Freeman et al.`05) for percutaneous attempts to alter the internal disk mechanics or denervation by either radiofrequency energy or heat as IDET (intradiskal electrothermal treatment). One expensive unblinded IDET trial found slight pain scale benefit in highly selected subjects but was also of no clinical significance (Pauza et al.,`03) Not surprisingly both are based upon a discography diagnosis.
Discography injection is invasive and difficult to justify considering high level studies. First, discography injection can stimulate pain not originating from disk (Carragee et al.`99)1.Second, pain on injection is found in 30-80% with prior disk surgery, psychological distress, remote chronic pain or disputed compensation claims, (Carragee et al`00,
Carragee et al`00). Third, no difference is found in outcome for spinal fusion with or without pre-operative discography (Madan et al.`02)
Fusion for Disk disease? Restoring Function & Adaptive Treatment & Inactivity Prevention have a better record than medically or surgically treating common spinal changes (Carragee`05 [persistent] ). Though the "Quality of life" improvement is not near levels found in the normal population, %-wise Quality, improves more with disc hernia and spinal stenosis surgery than for Total Hip Replacement or Total Knee Replacement, (Larsson et al.`04, Hansson et al.`04). Unfortunately, such improvement tends only to be the case in those who do NOT carry the non-physical complicating factors of the chronically disabled.
Chronic Low Back Disability calls for extremely conservative medical/surgical treatment of pain with Care that coaches coping with the emphasizes activity to regain function. Continually pursuing the potential source of pain should NOT go beyond the vigilant constraints of monitoring Red Flags.
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