Handbook of Pain Mgmt. - A Clin. Comp. to Txtbk. of Pain
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There are three broad questions for which clinical research would be particularly useful:.
Comprehensive Treatment of Chronic Pain by Medical, Interventional, and Integrative Approaches
For what types of patients and in what circumstances does acute pain progress to chronic disabling pain, and can these patients at risk be identified early? What specific treatment modalities are effective for which patients, and how do particular aspects of the doctor-patient relationship influence the effectiveness of treatment? What are the optimal times in the pain-disability course for particular kinds of interventions? As discussed in Chapter 6 , less than 10 percent of people with acute back pain develop chronic disabling pain.
If those people who are at risk for long-term illness and impairment could be identified early, it might be possible to design more effective treatment plans that could prevent long-term chronicity for at least some patients. At this time certain factors are known to be correlated with long-term problems, but they are not useful as predictive factors. More detailed patient typologies and classifications based on the development of chronic pain and disability are needed. There is a paucity of data in the literature about the effectiveness of diagnostic tools including the history-taking interview and physical examination and treatment modalities for pain.
The Quebec Task Force on Spinal Disorders Spitzer and Task Force, concluded that methods of treating chronic pain are, by and large, untested in well-controlled clinical trials. Few treatments have been shown to improve the natural history of nonspecific spinal disorders.
Clearly, there is a need to assess interventions in order to see what works alone or in combination and for which kinds of patients.
Among the treatments that should be evaluated are some of the alternative care therapies offered by chiropractors, holistic health care practitioners, and others that were discussed in Chapter 8. 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 healing 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?
Are particular therapies effective only with individuals with certain group affiliations or personal characteristics? Do certain alternative therapies have potentially harmful effects that may exacerbate pain and disability? If, as a few studies suggest, outcomes depend on the characteristics of the provider more than on the actual techniques used, such findings may point the way to specific alterations in physician behavior or in the doctor-patient relationship that will promote rehabilitation and recovery.
Finally, there is a very critical question about the optimal timing of interventions. Intuitively it makes sense to suggest that early attention to psychosocial problems might alter subsequent illness behaviors and mitigate the long-term negative consequences of pain.
However, this has not been adequately tested. Generally, clinicians agree that the longer people have been impaired, the harder it is to treat or rehabilitate them see Chapter What is not known is whether early interventions and rehabilitation efforts prevent later problems.
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Caldwell Memorial Pain Management Center
Search term. Back pain has been selected as the primary focus of this chapter because 1 more clinical, epidemiological, and administrative information is available on it than for other pain sites; 2 musculoskeletal pain, especially chronic low back pain, is the most common of the problematic cases for the disability system; and 3 back pain is illustrative of many of the clinical issues surrounding the chronic pain state in general Drossman, Clinical Decision Making Clinical decision making is a process that unfolds over time.
The Diagnostic Process The medical paradigm is relied on to provide the logic for clinical decision making. To illustrate, Wilson and Levine , writing about history-taking in Arthritis and Allied Conditions , advise a carefully taken history will help greatly to ascertain cause. Treatment of the Pain and the Disorder: The Medical Model In the treatment of chronic low 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, : 1.
Diagnosing and Managing the Patient with Pain: An Expanded Model Conventional understandings of disease fail to explain why people may be disabled by pain in the absence of a disease process that adequately accounts for the severity of symptoms. These clinical concerns about the patient are not new. Writing about pain in , Cabot noted In many cases a strong neurotic element can be traced—the mental or nervous weakness acting on the back through a reduction of muscle tone.
Guide for Authors
In addition to the inadequacies of a narrow medical model, there may be several other reasons why a diagnosis is not found: 1. Unknown Disease Processes If the patient has a disease that is, as yet, unrecognized, or one for which no specific diagnostic test has been developed, it will be impossible to make a diagnosis. 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.
Controversial Diagnoses The majority of patients with chronic back pain are cared for by internists or family practitioners whose conceptions of etiology are similar to those of orthopedics.
Trigger points, which may develop in any of the approximately skeletal muscles, have five cardinal features that distinguish them from other musculoskeletal disorders Travell and Simons, ; Simons and Travell, : 1. Fibrositis or Fibromyalgia Many rheumatologists and some other physicians who treat chronic musculoskeletal pain consider fibrositis or fibromyalgia to be a frequently overlooked source of chronic pain Wolfe and Cathey, ; Bennett, ; Campbell et el. 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, ; Dvorak et al.
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.
Diagnosis Because the development and persistence of chronic pain including back pain and impairment depend so importantly on psychosocial factors, attention to these factors is essential for diagnosis, treatment, prevention, and rehabilitation. Treatment Of Chronic Pain It is beyond the scope of this volume to specify treatment protocols in detail, but two general issues should be highlighted.
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Orienting medical practice to a more behavioral and preventive mode suggests some important principles in the care of pain patients: Detailed explanation of the cause of pain should be provided to patients, insofar as the cause is understood, while acknowledging the attributions of the patient. Instruction in medication use should be explicit to assure maximual control of pain with regular schedules and to avoid overprescribing. Return visits should be organized to reinforce suggested behaviors, provide support, and alter therapy if needed. Collaborative care should be arranged when psychosocial factors require specific therapeutic interventions.
Such referrals occur infrequently despite the well-documented frequency of psychosocial impairments in chronic pain patients Sternbach, and despite the promise that such consultations hold for more comprehensive diagnosis and complementary psychosocial therapies that could aid in the treatment of chronic pain.
Referral to a mental health professional or other specialist requires the primary care physician to orchestrate collaborative care. Coordination can be difficult for the solo practitioner because it requires frequent direct communication with colleagues.
In multidisciplinary pain clinics and rehabilitation centers, such collaborative care usually is explicitly organized see Chapter 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 low back pain and exacerbations of chronic low back pain. Drug Therapy Analgesics narcotic and non-narcotic and muscle relaxants benzodiazepines and non-benzodiazepines are very commonly prescribed for back pain.
Surgical Treatment Although surgical treatment can be dramatically helpful for a high percentage of patients with acute sciatica due to a herniated lumbar disc, resulting in prompt and effective relief of leg pain in at least 95 percent of them, not all patients with lumbar disc rupture require surgery. Recommendations For Clinical Research This overview of how chronic pain is handled in clinical practice highlights a number of areas in which current practice appears to be inadequate and perhaps harmful , and in which the rationale for physicians' behavior is based more on medical tradition than on the demonstrated efficacy of particular techniques or strategies.
There are three broad questions for which clinical research would be particularly useful: 1. References Ananth, J. Physical illness and psychiatric disorders. Comprehensive Psychiatry , Barr, J.
Back Pain - Invasive Procedures - Medical Clinical Policy Bulletins | Aetna
Ruptured intervertebral disc and sciatic pain. Journal of Bone and Joint Surgery , Bennett, R. American Journal of Medicine 81 3A , Fibrositis: misnomer for a common rheumatic disorder. Western Journal of Medicine , Bourdillon, J. Spinal Manipulation , 3rd Ed. Heinemann, W.
London: Appleton, Century, Crofts, Cabot, R. Differential Diagnosis. Philadelphia: Saunders, Cailliet, R. Low Back Pain Syndrome. Philadelphia: F. Davis, Campbell, S. Clinical characteristics of fibrositis. A "blinded," controlled study of symptoms and tender points. Arthritis and Rheumatism , Cassell, E. The Healer's Art.