Chris Smyth, Health Editor
The Times
Gerry Gajadharsingh writes:
I guess many patients may find this report challenging.
Pain is an important presenting symptom to may Osteopaths. The researchers are being blunt but probably truthful when they flag up that medicine often doesn’t not know what causes chronic back pain in many patients. The problem is the paradigm that medicine uses, trying to find a pathological (medical) cause for the pain when it reality the vast majority of these problems are “functional”. The mechanisms of pain are complicated, and I suspect that better management of patients when their pain develops may prevent many of them progressing to chronic pain. Medication can be useful in the acute stages of pain once both the clinician and patient have an understanding of the cause of the pain.
There are a large proportion of patients presenting to GP’s who have medically unexplained symptoms, chronic pain makes up a large part of those presentations. In my experience there are numerous factors which can predispose and maintain chronic pain. It’s often telling that some patients say, “I hope that it’s not stress”. The right sort of exercise (this is not as simple as it sounds), appropriate manual treatment, understanding their biochemistry (inflammation and poor muscle physiology can play a big part) and helping patients with the psycho-social factors that are underlying their pain often provides the best management.
Injections and surgery can play its part if it is targeted appropriately. Sadly, many patients, who are poorly managed end up progressing to these interventions as they have not responded to more conservative measures with minimally effective results. The research says that 20% of surgical intervention makes their problem worse.
Many people ask me what I do. I often reply that I help people change their belief systems. It is often the case that the patient’s belief about their pain is outdated and it needs to be reset. It is evident that what they are doing is not working.
The concept of central nervous system sensitisation, I think gives us a valuable mechanism for the continuing of many chronic pain syndromes. Essentially the brain and nervous system becomes hard wired. Measuring Heart Rate Variability (HRV) gives us an insight into the patient’s autonomic nervous system and how “stress” is affecting it. Many patients are in a state of sympathetic upregulation (the stress system is constantly on). Helping patients develop tolls such as relaxed breathing with biofeedback can really be helpful.
Trying to get a patient off opiates is extremely challenging, analgesia, especially opiates often causes rebound pain, when the meds wear off the pain returns so they take more, and a viscous circle develops.
Really helping patients with chronic pain is time consuming. A clinician has to really “listen” to the patients story, has to have a good working knowledge of medicine (in case pathology is present and has been missed), a good working knowledge of functional medicine (biochemistry, neuromuscular and psycho-social factors), to investigate appropriately if it is thought that investigations may be helpful (often they are not in chronic pain as the patient has often been investigated extensively). This leads to a more “holistic” approach to the patient (not just their pain). Patients for their part have to accept that sometimes conventional medicine doesn’t have the answer but there are clinicians out there who can approach patients holistically and for many patients can provide a better solution long term solution.
Millions of patients with back pain are being given pointless drugs, surgery and injections, with a third prescribed dangerous opioids, experts say.
Doctors prefer to offer useless and often harmful treatments rather than tell patients there is nothing to be done except stay active, an international group of scientists has found.
Exercise and psychological therapy are the only things that work for most cases of chronic back pain but too many people wrongly believe the myth that rest is best for the condition, they add.
Job satisfaction and a positive attitude are among the strongest indicators of whether back pain will turn into serious disability but their report, published today, says doctors are reluctant to discuss social and psychological approaches, preferring needless scans.
Back pain is the world’s leading cause of disability, with up to nine million estimated to suffer from it in Britain and half a billion worldwide, but a series in The Lancet says that it is routinely badly treated. In Britain one in seven GP appointments is for muscle and nerve problems, mostly back pain.
NHS guidelines recommend mainly exercise and therapy but Martin Underwood of the University of Warwick, one of the series’ authors, says they are often ignored. “In this country it affects a huge number of people,” he said. “It’s something that we’re not very well equipped to deal with. Patients understandably look for solutions and a cure, but the reality is we don’t have a cure. We don’t understand what causes the vast majority of back pain.”
Steroid injections are increasing, as are scans that often lead to surgery, a fifth of which actually makes the problem worse, Professor Underwood said. “The evidence underpinning these invasive treatments is very weak indeed. And they have harms.”
He pointed to studies showing that a third of British patients with back pain are given opioids such as tramadol, codeine and morphine but said: “If anything the evidence is that [opioids] can end up making your pain worse.”
About 24 million opioid prescriptions are written by GPs each year, double the figure a decade ago. Ministers have launched a review into concerns that patients are becoming hooked and suffering dangerous side-effects.
Past studies have found that pills like paracetamol and ibuprofen barely help with back pain. Psychological techniques to help cope with pain can stop it leading to permanent disability, however. “Your belief system and psychological state are important predictors of whether you’re going to end up disabled. It’s a difficult message to get across,” Professor Underwood said.