Monday, February 09, 2004

Back pain: an untreatable condition? NYT

Healing a Bad Back Is Often an Effort in Painful Futility
Americans $26 billion a year, or 2.5 percent of the total health care bill, according to a new study from Duke University, and far more if disability payments, workers' compensation and lost wages are taken into account. The costs are rising, researchers say, as patients get ever more aggressive forms of treatment...

Yet for all the costs, for all the hours spent in doctors' offices and operating suites, for all the massage therapy and acupuncture and spinal manipulations, study after study is leading medical experts to ask what, if anything, is doing any good.

A variety of studies have suggested that in 85 percent of cases it is impossible to say why a person's back hurts, said Dr. Richard Deyo, a professor of medicine and health services at the University of Washington. And most of the time, the pain goes away with or without medical treatment.

"Nearly everyone gets better, nearly everyone improves," said Dr. Deyo, citing evidence from large epidemiological studies. But he cautioned, "Getting better doesn't necessarily mean pain-free."

Surgery, too, is under new scrutiny, with a national study getting started at 11 medical centers. About 1,000 patients with the problems that most often lead to surgery will be randomly assigned to have surgery or not. The problems under study are herniated disks, spinal stenosis, which is a narrowing of the spinal canal that usually occurs with arthritis and aging, and degenerative spondylolithesis, a slipped vertebra.

One of the investigators in the study is Dr. James N. Weinstein, a Dartmouth professor of orthopedics and community and family medicine and the editor in chief of Spine, the professional journal that published the Duke report in its January issue.

"I've met with two groups who said they fear the results will take away their practice," Dr. Weinstein said. "I don't know how to deal with that. I don't know what the results will be."

Back experts say it is clear that surgery can make some patients feel better immediately.

"Let's say you have a herniated disk and let's say you have leg pain and let's say you are as miserable as hell and you convince somebody to operate on you," said Dr. Michael Modic, chairman of the radiology department at the Cleveland Clinic. "You have a 95 percent chance of waking up with no pain."

... Those with disabling pain for three or four months have just a 10 percent to 20 percent chance of getting better in the next year.

For this group, some doctors are now advocating a different approach altogether: teaching people to live with pain, to put aside the understandable fear that any motion will aggravate their injury. They have to learn, Dr. Weinstein said, that "hurt doesn't mean harm."

In programs often known as functional restoration, that is the goal. Patients are trained in strength, flexibility and endurance. They are counseled about their fears of re-injury and about anxiety and depression.

It can be difficult to get them back to work, noted Dr. Bigos, of the University of Washington, because many left their jobs on disability and had bitter disputes with their former employers or with insurance companies. "Usually, lines have been drawn in the sand by one or both sides," he said.

But success is possible, said Dr. Thomas Mayer, director of a clinic called Pride, for Productive Rehabilitation Institute of Dallas for Ergonomics. Among the 3,500 back patients who entered his one- to two-month program and completed it, almost all returned to work and nearly half went back to their original employer, Dr. Mayer said.

"We deal with it face on," Dr. Mayer said. "What are you going to do for the rest of your life? What are you getting from being disabled? What would you get if you were not disabled?"...

This short article is packed with a lot of interesting information. There's an unexplored backstory as well. In the 1980s a federal agency (AHCPR) published guidelines on back pain that deemphasized interventions and studies. A backlash led by orthopedic surgeons essentially destroyed the AHCPR. The AHCPR entered a witness protection program, changed its name, and now lives a quiet but useful life.

Overall the results would come as little surprise to most physicians. I think most family doctors have slowly come to much the same opinion. Exercise and weight control seem to be the only truly useful interventions. In the 1990s there was muted enthusiasm for prolonged narcotic therapy, but that appears to have waned. Chronic narcotics work for some, but misuse harms others -- overall a weak solution.

At the same time as we shift to managing chronic back pain through lifestyle changes and pain management techniques (neither of which will be adequately funded -- it's far easier to get compensation for surgery), we also have research showing a relationship between persistent pain, brain atrophy, and the development of distributed hypersensitivity to pain.

Short of radically reengineering the human back, or moving into the sea, we're stuck with back problems. It's one of our design flaws (the others relating to the fragility of cognition). A weight loss pill will help some, but many people with chronic back pain are not significantly overweight. A drug that reduced the brain's maladaptive response to chronic pain would be even better.

Update 8/1/2010: I was wrong about this. There are good interventions.

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