Chronic Low Back Pain and Fibromayalgia

A recent article discussed the number of patients with Chronic Low Back Pain (CLBP) who also had Fibromyalgia syndrome (FMS). This article is an example of the confusion in medicine about both conditions. Believe it or not although the most common diagnosis for low back pain is non-specific low back pain, referring to sprains and strains of muscles and other soft tissue, there is no agreed method to look for and treat muscle generated low back pain. Patients with
Fibromyalgia on the other hand, although complaining of pain in muscles, are for the most part not considered to have muscles as the cause of their pain but rather problems in their nerves that are experienced as pain in muscles.
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Back Pain Treatment

Please refer back to the past two blogs to find the background material for todays blog. Although the number of CARF approved pain centers in the US halved, the number of outpatient pain centers mushroomed. The services provided however focused on two areas:

  1. Medication management
  2. Nerve blocks and other invasive procedures.

Although many patients could be helped with one or both of these approaches, many patients in need of physical therapy and psychological services that were integrated with the overall treatment plan, would no longer receive optimal treatment. Reimbursement would be the driver of care rather than the needs of the patient. Centers could not stay in business and provide care that insurance companies would not cover. The shift toward procedures became an accepted standard of care and new organizations of pain physicians were formed whose membership focused predominantly on invasive procedures.
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Multi-disciplinary Pain Centers rise and fall

John Bonica, M.D. a world renowned anesthesiologist at the University of Washington in Seattle was the individual most responsible for the creation of a new specialty, Pain Medicine. In 1977 The American Pain Society was founded and became the United States national chapter in the International Association for the Study of Pain. Complicated difficult to treat pain patients were usually not successfully treated by a physician representing one medical discipline and thus the multi-disciplinary pain treatment model was created.

It was understood that belief systems about the patients’ pain such as –“having pain means I am harming myself “ resulting in the avoidance of activities that produce discomfort and eventually eliminating many important activities in the patients life with resulting deconditioning, depression, pain drug use, dollars spent and ultimately disability. Pain becomes the focus of life and the more it is pondered the worse it feels. Multi-disciplinary teams composed of a pain management physician, psychiatrist, psychologist, social worker, occupational therapist, physical therapist and pain team nurses provide weeks of intensive full day treatment programs with remarkable success in restoring function to patients disabled with persistent pain.
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History of the concept of the spine as the cause of back pain

Back pain can be found in the medical literature as far back as 1500 B.C. in Egypt.
Through the ages various explanations have been offered to explain the cause and how to treat it.  But it wasn’t until the 19th century that the spine and the nervous system were seen as the fundamental source of back pain. The idea that the cause of back pain was some injury or irritation in the bones and nerves of the spine was adopted by the medical community and this notion has persisted up to the present. With this in mind, recommending bed rest made sense-so bed rest became a standard treatment through most of the 20th century.  Some savvy physicians recommended staying active, but their opinion was drowned out by the bed rest proponents. If you have an injury it can take weeks to heal, and therefore it was common to have patients with back pain lie in bed, often in a hospital, sometimes without even getting up to go to the bathroom, for two or more weeks. It was only at the end of the 20th century, that the medical community recognized two facts:1. Back pain was usually not from any obvious injury. 2. Prolonged bed rest was not only not helpful, it was damaging. So patients with typical back pain began to be encouraged to remain active and to return to work as quickly as possible.
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Spinal fusion surgery for back pain was reviewed in three articles in the Journal of the American Medical Association this week http://cot.ag/bjDgWW . The sobering conclusions were that we are spending up to 10 times more for complicated new surgical procedures and frequently getting worse outcomes and up to twice as many complications.

 

Unfortunately, this is nothing new in the history of back pain treatment. An article in Spine http://cot.ag/dASfWh analyzed the cost of the treatment of back and low back pain in the United States.  It found that the cost of care from 1997 to 2005 went up from $62 billion to $86 billion and at the same time the number of patients reporting difficulty in functioning because of their pain also went up by 25%. Spending 65% more ($34 billion) resulted in worse outcomes.
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History of Muscle Pain

A review of comprehensive pain treatment textbooks finds no chapters dealing with muscle pain aside from sections on “Myofascial Pain Syndrome” discussing “trigger points” as the defining characteristic of syndromes with painful muscles. This points up a fundamental problem in discussing and understanding clinical muscle pain- the lack of agreed terminology to describe what is found when a painful muscle is examined. All muscle pain logically cannot be the result of trigger points. Treating every patient with tender muscles with injections will frequently result in failure to eliminate the pain. To better appreciate this lack of understanding, the history of muscle pain should be reviewed.
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Pain Medications in the News

Back pain that never goes away completely can undermine your quality of life. It can prevent you from participating in activities that bring you pleasure and security. The medications that we use to deal with the pain, while being life-savers in terms of providing relief from the suffering, expose us to potential harm.

Tylenol (acetaminophen) has been found to result in more than 40,000 cases of liver damge each year in the US. Some of these patients have died. Because of the misuse of this generally well tolerated drug, the FDA will limit its availability in combination drug products such as Percocet and Vicodin. The recommended upper limit has been 4000 mgms but will probably be reduced in the near future . A regular dose Tylenol tablet is 325 mgms, making twelve the maximum number of tablets/day. When you take the combinaton drug you may not be aware that you are ingesting the same drug as in Tylenol and inadvertently take a harmful overdose.
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What causes my back pain?

With severe back pain we frequently worry about having a herniated disc. If you have back pain and get an MRI chances are you’ll find something. At NY Hospital/Weill-Cornell, 90% of the MRIs of the low back are read as abnormal. But most back pain is diagnosed as “Idiopathic /Non-specific”, referring to sprains and strains of soft tissue such as muscle. But common soft tissue problems are not seen on the MRI so we often incorrectly assume that what we see on the image, such as disc herniaton/bulge, degenerated discs, spinal stenosis, facet arthritis, spondylolisthesis, is the cause of the pain. When we treat these “causes” we have many failures. Actually in some studies more than 50% of the back surgeries are unsuccessful leading to a new diagnosis, Failed Back Surgery Syndrome. Some clinicians recognize that muscles could be a source of the back pain and have attempted to treat the muscle that they have identified by applying pressure (palpation) to the suspected painful muscle. There are a variety of treatments that are offered. I will discuss some of them next time.

~Norman J. Marcus, MD
Norman Marcus Pain Institute, New York NY 
 
“Your New York City Pain Relief Doctor”
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The Blog to Illuminate and Eliminate Chronic Pain

It is my wish to inform patients and colleagues about the possibilities of eliminating pain even when it is thought to be permanent (chronic) or require an invasive proceedure such as surgery, nerve injections, spinal cord stimulation or a morphine pump to achieve any relief.

Our story begins with the recogniton that the current standard of care doesn’t work very well. An article in the Jouranl of the American Medical Association (JAMA), in February, 2008, by Martin, Deyo, et al.. reported that even though the cost of neck and low back pain in the USA increased from $26 billion in 1997 to $86 billion in 2005, there was no improvement in treatment outcome. $86 billion is also the amount we spend on cancer.

Actually patients were reporting that they were more impaired by neck and back pain in 2005 than in 1997. It appears that the reasons that we frequently offer to explain low back pain such as herniated discs, degenerated discs, arthritis, and spinal stenosis, are frequently wrong since treating these so called causes results in no, or partial, temporary improvement. What is missing from the published diagnosis and treatment guidelines for common pain problems such as low back, neck and shoulder pain, is any approach which addresses muscles as the primary source of pain.

In future postings we will look at some reasons why muscles are ignored and what you can do about it.

~ Norman Marcus, MD
Norman Marcus Pain Institute, New York NY
 
“Your New York City Pain Relief Doctor”
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