Pauline Anderson

Medscape

Gerry Gajadharsingh writes:

 Finally, researchers and clinicians are waking up to the idea that causes of pain (especially chronic pain) needs to be addressed in a more holistic way. The research below points out that current approaches to treating the condition often fail to address psychosocial factors that have been repeatedly demonstrated to predict pain-related outcomes affecting chronic pain and that the “typical order of care” for such patients is “highly medicalized”.

 The problem with medicine is it tends to provoke fear in many patients. Pain as a symptom is also a major cause of fear. Helping patients understand that in the majority of cases, especially with musculoskeletal pain, it is non-life threatening. A diagnosis that is understandable to the patient, framed in a way that makes sense, takes into the account the question of “why now” and a logical approach to its management, taking into account the patients beliefs can go a long way to stop pain becoming chronic.

 The research below focuses on CBT, which seems to be the new fad in the therapy world, but as with many things it doesn’t work for everybody. Approaching patients in an individualised way and developing treatment and management strategies that takes into account the way that “their” minds work, would be infinitely better.

 One of the commentators says “results highlight the importance of interdisciplinary care for patients with chronic low back pain”.  Whilst interdisciplinary care (we tend to use multidisciplinary) is a step forward, surely the first step is the diagnosis of the problem in an integrated way, understanding all the factors that are causing the pain. There are usually many. Medicine has a habit of wanting to find “the one problem”. Human physiology is complicated and numerous factors are at play in driving pain. Clinicians need to understand this first most important step, otherwise they will continue to struggle (as will their patients) to achieve successful resolution to problems.

 Proviso, some patients can’t be helped, in many experience many can.

 

VANCOUVER, British Columbia — A 12-week rehabilitation program that offers cognitive-behavioural therapy (CBT) in addition to physical therapy is proving beneficial for patients with chronic low back pain.

Results of a new study show patients completing the program improved on several outcomes, including the extent to which pain interfered with daily life, perceived disability, depression, and anxiety.

“We’re hoping that this is something that can change the way chronic low back pain is treated,” author Sarah Rispinto, PhD, a psychologist at the Cleveland Clinic in Ohio, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Major Public Health Problem

Chronic back pain is a major public health problem. Current approaches to treating the condition often fail to address psychosocial factors that have been repeatedly demonstrated to predict pain-related outcomes affecting chronic pain.

The “typical order of care” for such patients is “highly medicalized,” said Rispinto.

In 2016, the Cleveland Clinic launched the Back on TREK program, where frontline behavioural medicine specialists and physical therapists teach patients self-management using CBT for pain and psychologically informed physical therapy.

Researchers collected data on 116 patients who had chronic low back pain for at least 3 months. Over 12 weeks, study participants devoted at least 1 hour three times a week to individual and group sessions focusing on physical or behavioural therapy.

At the beginning and end of the program, study participants completed the Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System (PROMIS) assessments.

The study revealed clinically significant changes across multiple functional measures, including the ODI and all PROMIS measure subscales (such as social role satisfaction, fatigue, pain and global physical health).

Another PROMIS subscale that assesses the degree to which pain interferes with functioning also improved.

Close to half of the participants completing the program showed clinically significant changes in depression and anxiety.

This initiative aims to change the standard of care for back pain, said Rispinto.

“We’re hoping that patients try this interdisciplinary approach first, that this can be a first-line treatment as opposed to a tertiary approach.”

Rispinto and colleagues are now assessing whether the program affected opioid use.

“One of the goals of the program is to reduce the reliance on opioids, so we’re hoping to look into that to see how much of a reduction there was — how many patients came into the program on opioids, and how many were discharged without opioids.”

A future goal is to compare those who went through program to those who did not, said Rispinto. The investigators also want to replicate the program to treat other chronic conditions. Rispinto noted that many patients with chronic low back pain have comorbidities, such as fibromyalgia.

 Notable Exclusion

Commenting on the study for Medscape Medical News, Lynn Webster, MD, vice president of scientific affairs, PRA Health Sciences, Salt Lake City, Utah, said the results highlight the importance of interdisciplinary care for patients with chronic low back pain.

However, Webster noted that the study excluded patients with severe mental health instability.

“As with most interventions, the success of their treatment was influenced by the type of patients they enrolled in their study. A huge percentage of people with chronic back pain also have serious mental health disorders. We need to find solutions for this population as well.”

But the study results “show that nonpharmacologic treatments should be available for people who might benefit from the treatments,” said Webster.

No funding source or relevant financial relationships were reported

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 186. Presented April 27, 2018.