Gerry Gajadharsingh writes:
“My patient caseload tends to consist of complex patients, and obviously as an osteopath I also tend to see my share of back pain patients, although many with other problems/comorbidities.
Over the years I have lectured regularly in Germany and the article below is from a German Pain Specialist (doctor) giving his thoughts and insights into the management of both acute and chronic back pain.
The WHO characterises chronic pain as having multiple causes, framed within the biopsychosocial model or a biopsychosocial cause of pain. This encompasses both physical aspects, like functional impairment or failure, pathology and psychosocial aspects.
My patients are increasingly accepting that the causes of their back pain can often be in regard to functional impairment and psychosocial aspects, assuming there is no definitive pathology. It is the job of the clinician to explain to the patient the mechanisms behind how these factors may cause their pain. Without an adequate explanation and a chronology, many patients simply may not accept that the cause may be psychogenic or stress related.
Many patients during the history, deny any obvious precipitating factor in relation to stress, however as the history and examination goes on and with careful questioning the patient suddenly realises that there is often a lot of “stuff” going on in their life, which seems to be chronologically related to the onset of their back symptoms and can also often be described as a maintaining factor, especially in chronic back pain. And with many chronic pain syndromes, including chronic back pain, there is an element of central nervous system sensitisation something I’ve blogged on many times before.
Additionally, some patients suffering from endogenous depression, tend to somatise their complaints. In these cases, physical findings may be present, but the actual trigger is rooted in psychological factors.
Psychogenic factors are only revealed through psychometric tests and or a thorough psychological case history. The problem is that general practitioners don’t usually have the time for such in-depth evaluations. In contrast, a qualified pain therapist has 45 minutes for a first consultation, whereas in a GP practice, we’re talking about 15 minutes at best.
When I founded The Health Equation, over 20 years ago, we had several GPs working with us who could not understand why I spent 60 minutes with a new patient. After seeing my history, examination and sometimes remedial treatment also included during the first consultation for acute patients, with the information cleaned to write very comprehensive reports, they understood.
Spending time with patients, especially with chronic and complex patients is critical. It’s often necessary to sensitively delve into numerous factors, not only about their current presenting symptoms. It is often for many patients the first time that a clinician has taken the time to really understand them. I suspect this is a large part of starting their journey to get better, empathy and care goes a long way.
Two crucial considerations should guide the management:
Acute pain must be resolved swiftly to prevent it becoming chronic, short term appropriate medication can often play its part. However, many patients are still prescribed codeine-based medication. Recent WHO guidance suggests that this should not happen, because of the increased risk of addiction and rebound pain, when the medication wears off the pain flares up so the patient takes more medication and it turns into vicious circle.
The exact source of the pain must be investigated, usually by a detailed case history and appropriate clinical examination, sometimes accompanied by additional testing such as laboratory testing and or imaging.
The patient must be carefully examined to determine whether the physical origin is muscular, involves facet joints, or stems from a nerve root, disc or bone or a structure causing referred pain.
Nerve root pain or radiculopathy usually caused in the cervical (arm pain) or lumbar spine (leg pain) by some sort of disc protrusion or other reasons for foraminal entrapment (the space between two vertebrae where the roots emerge) can be extremely painful. What was interesting in the pandemic period, we heard of patients who couldn’t access NHS medical care, but for some their symptoms resolved but sometimes taking up to one year, some not resolving.
Sometimes acute pain is self-limiting, simple over the counter analgesia and or NSAID and time can really help. If pain continues or is very severe or there are complications such as potential nerve root entrapment or indeed suspicion of other underlying medical problems it’s important to seek an expert opinion from a clinician experienced in back pain, such as an Osteopath.”
Medscape
Ute Eppinger
Globally, 7.5% of people suffer from back pain, with nearly one third (31.4%) of the adult population in Germany affected. Beyond individual suffering, the costs to society are substantial. In 2020, the German Federal Statistical Office reported healthcare costs of 11.6€ billion for back-related illnesses, which corresponds to 2.8% of the total health expenditure of 431.8€ billion. From a cost perspective, back ailments surpass diabetes mellitus, strokes, and depression.
Dr Heinrich Binsfeld spoke with Medscape about the prevalence of back pain in Germany, and why the German Society for Pain Medicine (DGS) is increasingly focusing on psychogenic and social aspects of back pain. Additionally, he shared insights on what general practitioners should know to prevent chronic back pain and delved into the issue of whether surgery is performed too quickly. Binsfeld is vice president of the DGS, practises privately, and heads the DGS Pain Centre in Ahlen/Drensteinfurt, Germany.
What factors contribute to the high prevalence of back pain in Germany, and how does a sedentary lifestyle play a role?
Binsfeld: In industrial nations like Germany, people spend a lot of time sitting. Prolonged sitting puts strain on our bodies, leading to muscle dysfunction. Unlike in our more active evolutionary past, sitting fails to adequately train our muscles, resulting in a higher incidence of back pain. The substantial prevalence of back pain is linked to our predominantly sedentary lifestyle.
This contrasts with less industrialised countries where muscles are used more and there are fewer cases of back pain. However, this trend might shift in the next 20-30 years as industrialisation increases in Africa and Asia, fostering sedentary lifestyles and potentially increasing back pain cases.
The DSG focuses on psychogenic and social aspects of back pain alongside somatic factors at the annual German Pain and Palliative Care Day. What does this signify?
Binsfeld: The WHO characterises chronic pain as having multiple causes, framed within the biopsychosocial model or a biopsychosocial cause of pain. This encompasses both physical aspects, like functional impairment or failure, and psychosocial aspects.
For example, if a patient experiences workplace bullying, the illness can serve as an escape from this untenable situation. While addressing the physical aspects of the illness can be effective, sustained improvement is unlikely as long as the underlying psychogenic triggers remain unchanged.
Additionally, some patients suffering from endogenous depression tend to somatise their complaints. In these cases, physical findings may be present, but the actual trigger is rooted in psychological factors. This interplay extends to social aspects, where patients who have limited movement because of their pain may alter their social radius. They might avoid events and participate less in social life, which greatly hinders their recovery.
How do you assess psychogenic and social factors in back pain?
Binsfeld: In pain therapy, tools like iDocLive help identify issues like endogenous depression or anxiety disorders. Irregularities in psychometric tests prompt referrals to a psychiatrist specialising in chronic pain to evaluate why their psyche supports the pain. These psychometric tests are integral to chronic back pain treatment.
For acute pain, like lumbago, this doesn’t apply. It’s only when the pain can’t be acutely resolved and risks becoming chronic, that psychological and social factors become crucial.
What can general practitioners do to adequately consider psychogenic and social factors?
Binsfeld: Psychogenic factors are only revealed through psychometric tests and thorough psychological histories. The problem is that general practitioners don’t usually have the time for such in-depth evaluations. In contrast, a qualified pain therapist has 45 minutes for a first consultation, whereas in a GP practice, we’re talking about 15 minutes at best.
In my experience – and my patients are all referrals – such assessments are often overlooked in general practice. As a pain doctor, I have the time for these assessments, which general practitioners don’t; further complicated by a lack of reimbursement from health insurance companies.
What is particularly important for back pain management in general practice?
Binsfeld: Two crucial considerations should guide the management:
- Acute pain must be resolved swiftly to prevent it becoming chronic
- The exact source of the pain must be investigated
The patient must be carefully examined to determine whether the origin is muscular, involves facet joints, or stems from a nerve root.
For example, I recently treated a patient experiencing bilateral leg pain caused by severe circulatory disorders. Only an accurate diagnosis can lead to successful therapy.
When imaging is performed, it’s crucial to contextualise anatomical changes based on age. A 60-year-old patient will naturally exhibit different changes, considered normal for their age, compared with a 23-year-old.
Is surgery performed too quickly?
Binsfeld: Yes. For example, when a patient suspects a herniated disc, and MRI confirms it, the crucial question after physical examination and neurological consultation is whether surgery is an immediate necessity.
Before resorting to surgery, interventional attempts should be explored to alleviate the pain. Periradicular therapy (PRT) offers a nonsurgical option, involving injections to the nerve or affected disc. Three methods of PRT include ultrasound-guided, CT-guided (widely used nationwide), and C-arm, where the X-ray source and the detector are connected via the C-shaped arm, allowing X-rays from almost any angle.
While all three methods can be effective for facet joint diseases, when targeting the disc with PRT using CT (intraforaminal CT-guided injection), reaching the disc may be challenging. The C-arm method proves effective in this regard, but unfortunately, nationwide coverage and skilled interventionists in this technique are lacking. Additionally, few practices have a C-arm for outpatient use, and health insurance inadequately reimburses this treatment.
Due to these limitations, this effective method is rarely used in Germany. Injecting under ultrasound intraforaminally may not reach nerve roots in the spinal canal, and under CT intraforaminally, the medication fails to reach the correct spot in 80% of patients, resulting in insufficient pain relief. The misconception that interventional intraforaminal injections did not have a positive effect on the patient may lead to the wrong conclusion that interventional therapy is ineffective, pushing the patients towards surgery prematurely.
If PRT under C-arm had been attempted without pain relief, surgery would be justified. However, the reality is that the patient was treated incorrectly, using a technique that cannot help at all. Deciding on surgery based on this flawed premise indicates a hasty decision without exploring alternative and effective treatment methods.