Cannabis for Chronic Pain

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Legalising marijuana for either recreational or medical use makes lawmakers very popular

Canada is about to legalise marijuana.

 

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Really?  Does he need any more help?  

When it comes to the facts about  whether the use of cannabis for chronic pain is effective and worth some of the troublesome accompaniments that go with it, the lines can get a bit blurred.   Here in Oregon, where I am currently based, marijuana was legalized for recreational use just over a year ago but has been legal for medical purposes for more than 10 years.  A report in the local paper – The Oregonian,  suggests that one year on, the tax generated from the sale of pot accounted for just under $15 million, from sales of around $60 million, an impressive boost to the public purse for this relatively low population state.  However they also recognized that there had been a significant increase in people driving under the influence of marijuana, as well as calls to the poisons centre and visits to the emergency room for people who have over indulged.  The other obvious fears around such a move to decriminalize the drug – increases in psychological illness in adults who have been exposed to the drug in adolescence,  and the possibility of abuse or addiction, are yet to be examined due to the longitudinal nature of the studies needed to provide this data.  In Colorado, where marijuana was legalized in 2012, it was noticed that calls to the poisons centre went up by around 30% and that people self-reporting  to treatment centers increased by around 66%.

From the social side of the things, what I have found interesting living here is the reduction in stigma around the drug – the notion of which came wafting in my direction at a school fundraiser and social event that I recently attended.  Its just not a big deal.

For many countries or states trying to decide whether or not  to introduce the drug for medical purposes, it is hard to sort out the emotion from the science.  The emotive arguments can sometimes come across as if a lifesaving drug is being deliberately withheld.  There are certainly clinicians who report amazing and life changing results from observing patients using the drug for treating multiple sclerosis and nausea associated with chemotherapy.  However, like any drug used to treat a condition, we first of all need to know if it works, how well it works, and if the side effects or other issues associated with the drug outweighed by the benefits .

For treating chronic pain with medical marijuana, it seems like the answers are not straight forward.  The stigma and illegality of the drug certainly makes studying it trickier than it otherwise might be.  There is some evidence starting to trickle through – solid clinical trials showing good levels of efficacy.  However they are confounded by many problems – high drop out rates, difficulty in the standardization of the components or chemical make up of the product and  side effects, for example the inability to drive.

Two recent papers on the topic shed some light onto the effectiveness of the drug’s use in the treatment of chronic pain.  This study from 2015 combines data from both synthetic cannabis as well as herbal cannabis  (1).  The synthetic cannabis drugs that have been included in the review are dronabinol, Nabiximol and levonantradol, which are prescribed in some countries for the treatment of nausea associated with chemotherapy, wasting syndrome associated with AIDS, spasticity with MS and chronic neuropathic pain.  Overall this review suggests that there was moderate-quality evidence to suggest that cannabinoids (either herbal or synthetic) were effective at reducing pain in chronic pain states and treating spasticy, however the data for reducing nausea and improving appetite to prevent wasting in HIV whilst promising, was of a lower quality.  The review combined data from both cannabis that was smoked or eaten in a preparation with data from clinical trials on the synthetic cannabis, which it should be noted, have generally poor efficacy when reading their individual outcome studies.

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Herbal cannabis has up to 573 constituents  (2).  THC is the main psychoactive component which tends to cause the euphoria or relaxation effects as well as potentially contribute to anxiety and paranoia which can sometimes be experienced.  Other compounds that have an effect on the physiology are metabolites of the breakdown of the primary components.  The other notable component is cannabidiol (CBD), which does not cause psychotropic effects on its own and  is suggested to work to attenuate the anxiolytic effects of the THC  (3).  It should be noted that most of the synthetic forms of cannabis are purely THC based.  These include dronabinol and nabilone which have been trailed and used in the treatment of nausea associated with chemotherapy and spasticity associated with MS.  The small effect sizes that they have on these conditions doesn’t warrant much excitement (1).  Nabiximol, a synthetic mix of both THC and CBD analogues, is available for prescription in Canada and parts of Europe for treating pain, nausea and spacticity.  Again, the results are not that exciting and the side effects play into the decision for other countries not to license the drug.

A 2016 discussion paper suggests that the use of herbal cannabis (smoked, eaten or oil based)  in chronic pain settings (both nociceptive and neuropathic) resulted in VAS score reductions of 50% and 33% with numbers needed to treat (NNT) of 2 and 3.5 respectively.  These results were far superior to placebo and similar to reductions seen with the use of strong opioids  (4).  A difficult condition to treat,  drugs used to treat neuropathic pain, opioids and gabapentin,  have reported NNTs of 4.3 and 7.2 respectively  (5), well below the efficacy demonstrated in the above medical cannabis trials.   Another 2016 study also suggested that in states of the USA where medical marijuana has been legal for some time, there appears to be an associated statewide decrease in opioid use and thus a reduction in opioid associated deaths  (4).  These are probably statistics that should make us sit up and take notice. Opioid related deaths have increased dramatically in the last 10 years, alongside the increased prescription rates of opioids.  Additionally, opioids account for 75% of all overdose deaths in the USA  (6).  It is easy to see why some people are excited by the possibilities that cannabis seems to present.

Some clinicians are not convinced that the gains to be made are worth the hassle to overcome the problems associated with medical use of marijuana.  Dr Michael Vagg, a medical practitioner working in the field of pain in Geelong, Australia, wrote in his article in “The Conversation, AU” that the lack of research and heterogeneity of products leaves significant gaps in the decision to pursue the implementation  of medical marijuana.  He argues that the current state of evidence for the drug is not compelling enough to overcome the safety and quality and regulation issues.

So is the juice worth the squeeze?  Are we just swapping one set of side effects with another?  Is it the missing piece in the chronic pain puzzle that we have been waiting for?  The jury is still probably out and until we have a bigger evidence base to draw from we may not know.  It is certain that there are patients who will benefit from using this drug, but it is not without problems – do we swap opioid related deaths for DUI traffic deaths?   Many questions to be answered……  much pondering to be done…….  On that note, I might pop out and make the most of the greenery that Oregon has to offer.

I’m going for a walk in the forest, not to smoke a cheeky one!  😉

If you are interested in learning more about the studies of cannabis and chronic pain, as well as other pharmacological approaches to chronic pain, there is a 1 hour lecture available to purchase on our online teaching site here.  

 

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1. Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy S, Hernandez AV, et al. Cannabinoids for Medical Use: A Systematic Review and Meta-analysis. JAMA 2015;313:2456-73.

2. Savage SR, Romero-Sandoval A, Schatman M, Wallace M, Fanciullo G, McCarberg B, Ware M. Cannabis in Pain Treatment: Clinical and Research Considerations. J Pain 2016;17:654-68.

3. Ahrens J, Demir R, Leuwer M, de la Roche J, Krampfl K, Foadi N, et al. The nonpsychotropic cannabinoid cannabidiol modulates and directly activates alpha-1 and alpha-1-Beta glycine receptor function. Pharmacology 2009;83:217-22.

4. Boehnke KF, Litinas E, Clauw DJ. Medical Cannabis Use Is Associated With Decreased Opiate Medication Use in a Retrospective Cross-Sectional Survey of Patients With Chronic Pain. J Pain 2016;17:739-44.

5. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol 2015;14:162-73.

6. Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics: benefits versus harms of long-term therapy. Expert Rev Neurother 2013;13:1201-20.

Home birth – a discussion from my soapbox

Mention home birth in social discussion and depending on the social circle you are mixing with you may get extremely polarized opinions.  In the UK, government funded and supported home birth have been part of the NHS for many years.  It is seen as a great way to reduce the burden on hospital systems and allows women to labour and birth in a place that is relaxed and comfortable.  For low risk pregnancies it is safe option because of the infrastructure and systems incorporated into the process.

In Australia, the practice seems to be strongly discouraged by both the medical systems, and the government.  This means that the services available to the midwives facilitating home birth in the UK that make it a safe system, are not offered to mothers and midwives who chose to birth at home in Australia. A woman can still choose to birth at home, however the path is not smooth or easy.  Ultimately, without access to well facilitated hospital transfers, open and accessible sharing of medical records and welcomed co-management by the medical system, choosing a home birth in Australia is certainly not the path of least resistance.

For low risk pregnancies, a home birth with good medical backup and a shared care approach is a fairly safe option.  However for those choosing to go down that pathway in either  a higher risk category, or who are not able to access things like full medical records and easy systems to transfer to hospital when things aren’t going well, a home birth put both mother and baby at risk.  When both of these factors are at play it is a scenario for disaster – one that many might say is both entirely unnecessary.  I was recently promoted to read the coroners report in this tragic case in Melbourne in 2012 – an extremely distressing and sad tale that encapsulates many of these issues.

Knowing that no mother would ever deliberately put herself or her child at risk, what prompts a family to choose a scenario where the risks are perhaps questionably high compared to the benefits?  I believe that in these cases, the answer lies in a sense of injustice, disappointment, trauma and emptiness following an upsetting hospital birth scenario.  Emergency caesarians, situations where a woman and her partner are left feeling emotionally distraught, a perceived lack of support from busy midwives on the ward,  tiredness kicking in, breastfeeding issues, a sense of not being heard regarding medical care – the list could go on.    Even the very “best” birth and post partum experiences can leave a new mum feeling lost and confused.  Throw some traumatic experiences into the mix and a woman can leave hospital feeling angry, regretful, and resentful about her hospital experience.  Its not a big leap to see then that blaming the place and the people associated with those feelings is a potentially natural next step and walking away from those systems in subsequent pregnancies is somewhat understandable.

The main problem with this scenario is that the things that lead to the unpleasant scenarios in that birthing experience, potentially mean that any subsequent labour are predisposed to slightly higher risks.  If you had a post partum haemorrhage the first time, you have about a 14% chance of it happening in a subsequent pregnancy.  So, whilst it makes sense to not  want to go back to the place where all of this unfolded in the first instance, the body of evidence, says that this is exactly there you need to be.  I feel really strongly also, that in some instances, this  information is not taken full into account by both a pregnant woman and her partner when making an informed choice – ultimately, for informed consent to be truly that, a full understanding of the risks versus benefits needs to be thoroughly explored.  This has to include a discussion of the  follow through of potential consequences for the partner and extended family – if a mother dies giving birth in a high risk home birth, do the partner and family believe that the risk benefits ratio fits with their situation – are they prepared to bring up the child or children on their own.  This decision is not just about the woman’s desires  but the whole family.

Whilst the desire to walk away from hospital and medical systems  makes some sense in these instances, I believe that the scenario could be avoided  with a relatively cheap, low risk, no side effect intervention in the weeks that follow birth- a session or two with someone from those hospital systems (preferably someone involved in the birth)  who can offer a listening ear, reassurance, education and a plan going forwards.  I believe that the missing link in many of these scenarios is just that sense of not being heard, combined with a lack of full understanding of what took place and why, and what the future consequences might be.  This is not to say that the existing systems don’t understand this, or try to implement such an approach, but recognises that resources are often limited and the capacity to offer such a service is limited.

Research tells us that not being heard is one of the primary complaints of patients utilizing  medical services.  The same series of studies also tells us that reassurance and education in itself can offer fantastic outcomes with regards to reducing distress and improving other outcomes.  We need to start seeing the time spent both listening and educating patients as a clinical entity in itself, and in doing so allowing the time and funding required to deliver it.

Shingles and Post Herpetic Neuralgia

Post Herpetic Neuralgia

The varicella zoster virus, also know as the chicken pox and shingles virus, is a type of herpes virus.  In younger people, it  causes the chicken pox.  The virus will then lay dormant in the dorsal root ganglion (bundles of nerves close to the spinal cord).  Most young adults who are tested will demonstrate seropositivity to the virus –  meaning that they carry the dormant virus and are at risk for it developing into shingles in older age.  Our immune system will tend to keep the virus in check, however as we age, the number of circulating antibodies that are specific to the virus tends to drop, and the virus can reactivate.  This results in a painful, blistering rash in a unilateral, single dermatome.  Acute pain in the distribution of the dermatome usually precedes the rash by 7-10 days (1-3).

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The rash will tend to heal in 2-4 weeks, but roughly 10- 27% of sufferers will go on to develop a condition known as post herpetic neuralgia (PHN) (4). This is a nasty, painful conditions that proves very difficult to treat.  The pain is described as being dull and constant or burning in nature, with many describing sharp, shooting pains as well.  Some people also find the area to be intensely  itchy.  This is not a fun condition and the burden of disease is huge.

The literature tells us that there are a few factors that can predict the likelihood of someone going on to develop PHN following the herpes zoster infection.  These include older age, a worse rash in terms of pain levels and severity of the rash, diabetes and involvement of the eye (3, 5).

Treating PHN is notoriously difficult.  Success is generally defined as a 30% reduction in symptoms, however only about half of people treated for the condition  will actually achieve this level of relief.   (1, 2, 6, 7).  The literature suggests that best treatment options are amytriptiline, gabapentin, lidocaine patches and perhaps even opioids.  Many times, a combination of several medications is required to achieve better outcomes (1).

Prevention is always better than cure and preventing PHN seems to come down to several factors.  Oral antiviral medications are effective at reducing the duration and severity of the shingles virus.  There is insufficient evidence to suggest that they are effective at reducing the development of post herpetic neuralgia, however there are some newer drugs on the market which are yet to be extensively investigated for their capacity to prevent the progression from acute pain to chronic pain  (8). The problem in the real world with such an intervention is that it needs to be taken within 72 hours of the rash appearing to be effective.  Patients may not present to doctor within that time, or the rash may be misdiagnosed.

The most obvious way to prevent PHN, is to prevent the population from getting shingles in the first place.  The shingles vaccine has been shown to reduce the occurrence of the virus by about 50%  in a vaccinated population.  Further, those who do get the disease following vaccination tend to have a milder rash and less pain  (8, 9).

Public health recommendations generally don’t support vaccination for people under 60.  This is based on data that says that it is not cost effective – the costs of vaccinating a population under 60 do not outweigh the costs associated with not vaccinating (treatment, medication and ongoing costs in the event of post herpetic neuralgia).  This is not the case in the population over 60 and it is generally recommended that people over that age get the vaccine   (4, 10).  However, we need to remember that public health decisions are exactly that – made for the public.  For the individual, the opportunity to reduce the chances of getting shingles and the subsequent change of that hanging around and becoming PHN, the choice is a no brainer – get the vaccination, even if you have to pay for it.

For primary healthcare practitioners, this is an easy chat to have with a patient over 50 that could save a lot of suffering for that individual.

1. Hadley GR, Gayle JA, Ripoll J, Jones MR, Argoff CE, Kaye RJ, Kaye AD. Post-herpetic Neuralgia: a Review. Curr Pain Headache Rep 2016;20:17.

2. Argoff CE, Katz N, Backonja M. Treatment of postherpetic neuralgia: a review of therapeutic options. J Pain Symptom Manage 2004;28:396-411.

3. Boogaard S, Heymans MW, de Vet HC, Peters ML, Loer SA, Zuurmond WW, Perez RS. Predictors of Persistent Neuropathic Pain–A Systematic Review. Pain Physician 2015;18:433-57.

4. Drolet M, Oxman MN, Levin MJ, Schmader KE, Johnson RW, Patrick D, et al. Vaccination against herpes zoster in developed countries: state of the evidence. Hum Vaccin Immunother 2013;9:1177-84.

5. Forbes HJ, Thomas SL, Smeeth L, Clayton T, Farmer R, Bhaskaran K, Langan SM. A systematic review and meta-analysis of risk factors for postherpetic neuralgia. Pain 2016;157:30-54.

6. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006;174:1589-94.

7. Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. The Lancet Neurology 2015;14:162-73.

8. Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014:CD006866.

9. Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2016;3:CD008858.

10. Le P, Rothberg MB. Cost-Effectiveness of Herpes Zoster Vaccine for Persons Aged 50 Years. Ann Intern Med 2015;163:489-97.

Students and New Graduates: leading the charge.

Get a few pain people together to talk about how we can change the face of healthcare to embrace a more current understanding of pain and reliably the conversation will head towards a consistent answer: students.

Reaching out to existing clinicians to get them on board with a more modern view of pain is tricky for a  few reasons:

  • Some of them don’t go along to appropriate professional development courses, choosing to fill their CPD quota with business marketing courses and therapeutic courses that fall well short of what I believe the public expect of government registered practitioners to fulfill every year.
  • Some of them have ventured into learning about pain science and find it too much of a paradigm shift because:
    • It invalidates their way of practice (it doesn’t necessarily)
    • It devalues their contribution to previous therapeutic successes (it doesn’t – it just my change their understanding of why such success was obtained)
    • It is a threat to business (it doesn’t have to be – we all need to move with the times.  Be thankful you are not a taxi driver in a city with Uber!)
    • It can feel to them like they are learning that the earth is flat.  The cognitive dissonance kicks in and they turn their back on it.
    • Having said that, not everyone is getting left behind. Clinicians are paying attention and pain science is is becoming more and more present in the mainstream.

But students and new graduates are the obvious way forward to create a generational change and shift in the way we deliver healthcare – one that fits a little more closely with our current scientific understanding.

Having been in contact with both students and new grads from universities in Australia and the USA in both osteopathy and physical therapy professions, I am confident that the wheels are in motion.  Students are embracing a biopsychosocial model in their early years and are clever enough to navigate a system where they are learning about social and psychological factors that influence pain in one class  and biomechanics based treatment approaches in the next class.  They are the first generation to be integrating this understanding from the get-go – and I envy them!

New graduates are equally important for us to be focusing our attention and mentoring skills towards.  No clinician can forget those early days going home after a crappy day thinking: “ I am just not doing it right – my patients are not getting better”.  That crushing feeling that your manual skills are just not up to scratch because you had this idea that you should be able to fix everything with your hands!  Despite having a better understanding of this as the “bio” bits of a biopsychosocial approach, it can still be difficult and in the event that they seek counsel from a clinician with a very “bio” understanding of pain, they can end up seriously disillusioned.  The weight of words from experienced and well respected clinicians can be enormous – especially, for example, when they are telling people that X-rays for an asymptomatic patient with a common spinal anomaly are needed.  Or perhaps even running courses that advocate such understandings.  How do we help a  new grad navigate this?  Some suggestions:

  • Mentor them – if you employ a new graduate in your clinic it is your responsibility to help shape their understanding, handle the tricky cases and integrate their knowledge with clinical pearls of wisdom.
  • Help them set out their professional education calendar for the first few, very influential years
  • Run a journal club with your own clinic or other local practitioners
  • Make observation of other practitioners a regular part of your clinic – we can all learn from each other and the feedback and scrutiny for the treating practitioner can be fantastic.
  • Sponsor or mentor a student – have them in regularly for a chat and some observation.  Pay for them to go along to courses that you think will benefit them.

A manual therapist NEVER needs an MRI to manage low back pain

This was written by Monica Noy and Alison Sim

A manual therapist NEVER needs an MRI to manage low back pain

– an opinion(ated) piece backed by research!

MRI findings will not change your management strategy

  • There is very little correlation between pain and findings on an MRI or other imaging. Vast numbers of pain free individuals have disc bulges or spinal degenerative changes present on MRI. (Brinjikji, Leutmer, Comstock… et al, 2015; Jensen, Bran-Zawadski, Obuchowski… et al, 1994; Suri, Boyko, Goldberg… et al, 2014)
  • If there are no red flags but you suspect a disc bulge or any form of spinal degeneration or osteoarthritis, an MRI might confirm (or not) those suspicions, but shouldn’t change your management strategy.
  • If there are radicular signs and symptoms (sensory changes in a dermatomal distribution, weakness, loss of reflexes) without progressive worsening, an MRI that has already been conducted tells you where the disc bulge is, or how big it is, but should not change your management strategy.
  • Best practice management in most back pain cases is conservative as illustrated by this handy, up to date guideline of management of acute low back pain with radicular signs and symptoms.
  • Red flags WILL change your management strategy. If there are red flags or if there are no changes to radicular signs and symptoms after 2-4 weeks of conservative approaches, or if there is a continual worsening of symptoms, a referral to the appropriate medical professional is required. They will decide if an MRI is an appropriate course of action to help them make the decisions that need to be made and if more invasive treatments might be warranted.

MRI findings can make people worse

How can a non-invasive imaging modality make someone with LBP worse?

One word – FEAR. Images of jam donuts with bright red jelly exploding out the side, threats of surgery, crumbling, crusty spines, horror stories about uncles, friends or cousins who ended up in wheel chairs or damaged by surgery, or not getting surgery.

Medical and manual therapy culture, and subsequently society at large have alarming things to say about disc bulges and osteoarthritis. But those alarming warnings about slippages and crippling dysfunction do not apply to the majority of LBP sufferers. Still, the myths are pervasive, and have a lot of staying power. The higher the fear, the worse the outcomes.

MRI findings are a waste of money

Not only do these images place a huge financial burden on individuals, health and insurance systems, there is plenty of evidence to show that they drive up both invasive interventions and cost in episodes of low back pain, regardless of the presence of radiculopathy. One study found that having an early MRI cost an average of around $13,000 in subsequent healthcare costs, compared to not having the MRI. (Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013.)  Just imagine what else could be done with that money!!

If MRI images provide questionably useful information that has no bearing on management or outcome, then we have little to no reason to seek these images, or request that our patient seeks them. (Rainville, Smeets, Bendix… et al, 2011; Webster, Bauer, YoonSun Choi, Cifuentes, & Pransky, 2013; Suri et al, 2014).

MRI findings are not a necessity

If you already reassure patients that their back pain is likely to get better, or assure them that an MRI isn’t necessary and/or follow other current guidelines for management of low back (Chou, Qaseem, Snow… et al, 2007) then your help is needed. We can encourage colleagues who still default to the idea that what they see in MRI or other imaging is going to inform their treatment to engage with the current scientific understanding of MRI imaging, symptom presentation, pain science and outcome management.

Continued discussions about whether the degeneration at L5/SI is causing pain are really unhelpful, for both patients and clinicians.

                       *****  It just doesn’t fit with the science *********

 

 

 

The Science

Images, information and further studies to help educate your patients on these issues:

https://ptbraintrust.wordpress.com/2016/05/09/patient-education-binder/

Brinjikji,W.,  Leutmer, P., Comstock B., … et al (2015).  Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

Chou, R., Qaseem, A., Snow, V., et al.(2007).  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal  Medicine, 147,478–91.

Suri, P., Boyko, E., Goldberg, J., Forsberg, C., &  Jarvik, J. (2014).  Longitudinal associations between incident lumbar spine MRI findings and chronic low back pain or radicular symptoms: retrospective analysis of data from the longitudinal assessment of imaging and disability of the back (LAIDBACK). BMC Musculoskeletal Disorders, 15,152.

Jensen,  M.,  Brant-Zawadski, M.,  Obuchowski, N., Modic, M., Malkasian, D.,& Ross, J. (1994) Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 69–73.

Rainville, J., Smeets, R., Bendix, T., Tveito, T., Poiraudeau, S., & Indahl, A. (2011).  Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice.  Spine Journal, 11(9), 895-903.

Webster, B., Bauer, A., YoonSun Choi, M., Cifuentes, M., & Pransky, G. (2013).  Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain. Spine, 38(22), 1939-1946.

Evidence Based Management of Acute Lumbar Disc Pain

2018 update: This information was originally for an assignment Alison did as part of the Masters of Pain Management.

We have updated the content and presented it as an infographic.

References

  • Australian Acute Musculoskeletal Pain Guidelines Group. (2003). Evidence based management of acute musculoskeletal pain. Accessed at: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp94.pdf
  • Anichini, G., Landi, A., Caporlingua, F., Beer-Furlan, A., Brogna, C., Delfini, R., Passacantilli, E. (2015) Lumbar endoscopic microdiscectomy: Where are we now? An updated literature review focused on clinical outcome, complications and rate of recurrence. Biomedical Research International. Epub 2015 Nov 24.
  • Cohen, S., Hanling, S., Bicket, M., White, R., Veizi, E….et al. (2016). Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. British Medical Journal. 350, h1748.
  • Goldberg, H., Firtch, W., Tyburski, M., Pressman, A., Ackerson, L…. et al. (2015). Oral steroids for acute radiculopathy due to a herniated lumbar disk: a randomized clinical trial. Journal of the American Medical Association, 19, 313(19), 1915-1923.
  • Kasimcan, O., & Kaptan, H.(2010). Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. Neurologica Medico- Chirurgica, 50,1070–3.
  • Kreiner, D., Hwang,S., Easa, J., Resnick, D., Baisden, J., ….. et al. (2014). An evidence based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine Journal, 14(1), 180-91.
  • Koes, B., van Tulder, M., Chung-Wei, C., Luciana, M., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12): 2075-2094.
  • Manchinkanti, L., Knezevic, N., Boswell, M., Kaye, A., & Hirsch, J. (2016). Epidural injections for lumbar radiculopathy and spinal stenosis: A comparative systematic review and meta-analysis. Pain Physician, 19(3):E365-410.
  • Nice Guideline (Draft): Low back pain and sciatica: management of low back pain and sciatica. Assessment and non invasive treatments. Feb 2016. https://www.nice.org.uk/guidance/GID-CGWAVE0681/documents/draft-guideline Up To Date: Approach to Acute Lumbosacral Radiculopathy. http://www.uptodate.com. Accessed 4/4/2010
  • Weinstein, J… et al. (2006). Surgical vs nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT): A randomized trial. Journal of the American Medical Association, 296(20), 2441-2450.
  • Williams, C., Maher, C., Latimer, J., McLachlan, A., Hancock, M., Day, R., & Lin, C. (2014). Efficacy of paracetamol for acute low back pain: a double blind, randomized controlled trial. Lancet, 384(9954), 1586-96.

Why the “WHY?” is so important

I’m sitting in a café, trying to mark exams (and stop procrastinating) and the ladies opposite me are having a fairly public and loud “nutrition consult”.  One is paying the other for her advice and is listening intently.  I promise I am trying hard not to listen… but it is so loud… and so….. interesting:

Client: So that is why my knees are giving me so much trouble?  Because of my diet?

“Nutrition” lady: Absolutely – your diet is so inflammatory, it is 100% causing your knees to get sore and probably also causing all sorts of other problems –  heart problems, digestive problems…..

Client: ooooooooooohhhhhh.  Woooooooooow!

“Nutrition” lady: you need to eat more Kale, melon, spinach, beans.  But NEVER eat raw broccoli and avoid pumpkin and cooked cauliflower – you can eat it raw but never cooked.  Eat blueberries and raspberries but NEVER strawberries – those babies are so bad for you………………  And it all must be organic…..

On and on it went.  The client left a little bewildered with a strange and random list, heading home via the organic shop to infuriate her family, friends and facebook friends with her new nonsense diet that was going to cure her knee pain and toxic liver.

Now can you see why I couldn’t concentrate?

The “why” behind our pain can tend to drive us to do some strange things – it is a big component of “the search” for the quick and easy answer to our pain.  If we can just find out the why, then we can do something about it and there is our answer.  Hooray!!!!!  If only it was that easy.

Looking for answers seems to be part of our culture – we are quick to blame, rather than attend to the problem in front of us.  My own example of this is my tension headaches – they come on occasionally, perhaps a couple of times a year, usually when I am burning the candle at both ends.  They tend to last a week or so and they suck!  They are a good empathy check for me to help deal with patients in pain.  My natural tendency is to go looking for a specific reason as to why they might have popped up this time – is it lack of sleep, stress, too much work on etc. Sometimes, I just can’t pin down a reason at all and I find this situation the most distressing – if I can’t even figure out what I have done to bring them on, how do I stop it from coming on again?  The desire to be in control in all aspects of my life is obviously a dominant one!   I have begun to reason with myself that perhaps I can’t be in control of these things – and that is OK!  I can generally keep doing what I need to do WITH a headache and I know it will go away in the near future.

Disengaging the patient away from looking for the “why” is a massive part of pain education.  Its also often the hardest part to shift – people have usually latched onto a “why” that may be incorrect but has meaning or makes sense to them.  They will often have fitted it into a rule type situation that looks like this:

When I _____________________________, ____________________________ happens.

For example,

When I  eat cooked cauliflower, my knees get really sore

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These are often incorrect and unhelpful understandings about a person’s individual situation.  Myth busting in these cases is an important part of pain education.  How we go about that is probably going to be the key to success or failure.  For example, laughing until you fall on the floor about the cauliflower probably isn’t going to work well as a rapport building exercise.  We need to remember that the desire to know why can be a powerful driver and disentangling that needs to be done delicately.  We also need to recognise that if we take away someone’s long held assumptions, we need to replace it with something that is accurate, tangible, reassuring  and helps them to look forward towards function, rather than keep looking for answers.  This is the essence of good pain education.

If I had 10 million dollars……

Is it just me or is there a growing sense in the community that health care delivery is not meeting the perceived needs of its consumers – patients and their families? “Google doctor” situations,  horror stories of friends and relatives, less than perfect outcomes…..  Bad experiences become folklore and bad news travels way faster than good stories.  I see it sometimes creating an “Us Vs Them” scenario in hospital and healthcare settings and I think it can tell us a lot about consumer expectations – they largely don’t seem to intersect with the realities of our health care systems. 

So with this in mind, is what we are doing in delivering health care falling short of the mark, or is it just that our patient’s expectations are not realistic?  The answer is:  probably a touch of both.

Qualitative research by Slade et al in 2009, paints a picture that by and large, patients want to be heard and understood.  They desired a therapeutic partnership that was neither clinician dominant nor patient driven – an equal working relationship.  We also know that for patients with back pain, one of the most common complaints they have about practitioners is that they don’t listen ( Allegretti, Andrew, Borkan et al, 2010; Stenberg,  Fjellman-Wiklund, & Ahlgren, 2012) and that when practitioners are trained in empathy techniques, patients tend to report that those practitioners are more caring.  (Bonvicini,  Perlin, Bylund….et al, 2009).  So it would seem that if we were to do a customer service overhaul to improve patient satisfaction (and likely clinical outcomes), a great place to start would be to allow more time for each patient so that they have the chance to feel heard and understood.

 

Getting the listening bits right seems like an easy start – to me it is a bit like the low hanging fruit.  But what happens when we have done all the listening and education that “best practice” tells us is the way forward, and the patient still wants “something to be done”  – an MRI to rule out the disc bulge like Aunty Mary had, or the antibiotics for their viral URTI?  Do our efforts need to be turned towards educating the doctor?

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Well, maybe, but probably not …….. This study by French et al, published in 2013, looked to educate general practitioners in best practice guidelines in the management of acute low back pain.  Largely, what they were looking for was: would educating doctors on this topic change their clinical behaviour in terms of reducing the use of imaging, keeping patients active, reassuring them and promoting self management?  The answer: a big fat no!  The doctor’s clinical behaviour did not change, despite their assurances after the training session that it would – months down the track their referral rates for imaging were just the same as prior to the training.  Speak to doctors at the coal face and the answer as to why this is becomes clear very quickly – patients demand action! Doctors are not stupid – they know the deal with management of low back – but the realities of their practice is that sometimes the patient is so insistent that even the best educational tools and reassurance don’t cut it.  They are on a tight schedule and are aware that the patient will go elsewhere anyway.

Soooooo……  Do we need to direct our attention to changing society’s understanding of conditions like back pain?  How easy is it to do this?  Do public education campaigns work?  A Cochrane review done in 2009 by Grilli, Ramsey and Minozzi tells us that although the body of evidence is not particularly large or of a very high quality, there is evidence that using mass media campaigns can change population attitudes and behaviour on topics such as HIV education, immunization rates and back surgery rates.  The study acknowledges a couple of important points.  Firstly, that it is hard to tell if the effects of the campaigns are coming about because of exposure of the material to the general population or because  health practitioners are also exposed to the campaign and adjust their behaviour.  Also, it recognises that while mass media can be a powerful tool in reaching people with education material, it may also play a role in shaping the damaging views people hold, such as those quick fix, miracle stories on the news or the sad (and often extreme)  stories of people going down a path of pain and disability.

In the case of back pain public health campaigns, the ‘Back Pain: Don’t take it lying down’ campaign, run by Victorian Workcover Authority (Australia) in 1997-1999 was hailed as being a small but successful public intervention.  Over the three year period that the campaign was run, it was found that there were significant improvements in back pain beliefs in both the nearly 5000 people surveyed in the general public and 2500 general practitioners (Buchbinder, 2008).  The flow on effects from these positive outcomes are hard to measure – but the campaign was prompted by high absenteeism in the workplace.  It wouldn’t be hard to account for the dollars spent if the subsequent clinical outcomes included reduced absenteeism and reductions in healthcare visits.

In addressing “risk” in public healthcare settings, there is said to be what is called a “prevention paradox” – this is the idea that there is a more substantial public health benefit from a small shift in risk across a large population, than from a large shift in risk for a small subgroup (perhaps even a high risk group). This fits with the idea that the shift needs to be population wide, and that even a small shift is a good start.

So, if I won 10 million dollars, would I spend it on a public health campaign to reduce the burden of low back pain on society?  Maybe…..  as long as I could manage the campaign from here:

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Allegretti, Andrew, Borkan, Jeffrey, Reis, Shmuel, & Griffiths, Frances. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683.

Bonvicini, K.A., Perlin, M.J., Bylund, C.L., Carroll, G., Rouse, R.A., & Goldstein, M.G. (2009). Impact of communication training on physician expression of empathy in patient encounters. Patient Education and Counseling, 75(1), 3-10.

Buchbinder, R. (2008).  Self-management education en masse: effectiveness of the Back Pain: Don’t Take it Lying Down mass media campaign.  Medical Journal of Australia, 17;189(10 Suppl), S29-32.

 

French, S., MckKenzie, J., O’Connor, D., Grimshaw, J., Mortimer, D……..et al.  (2013).  Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomized trial.  Plos One, 13;8(6):e65471. doi: 10.1371/journal.pone.0065471.

 

Slade, S., Molloy, E., & Keating, J. (2009).  ‘Listen to me, tell me’: a qualitative study of partnership in care for people with non-specific chronic low back pain.  Clinical Rehabilitation, 23(3), 270-80.

 

Grilli, R., Ramsay, C., Minozzi, S. (2002).  Mass media interventions: effects on health services utilization. Cochrane Database Systematic Reviews. CD000389

 

Stenberg, G., Fjellman-Wiklund, A., & Ahlgren, C. (2012). “Getting confirmation”: gender in expectations and experiences of healthcare for neck or back patients. Journal of  Rehabilitation Medicine , 44(2), 163-171

San Diego Pain Summit 2016

The second San Diego Pain Summit at times, felt more like the most fun school or friend re-union you could imagine, than an educational event!   Some of the people I was most excited to “catch-up” with, I had never actually met before in the flesh.  Pushing aside the fantastic social opportunities, the wonderful connections made and the beautiful setting, the program provided an exciting array of speakers who kept the audience engaged for the full two days.

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Kicking things off was a session run by Paul Lagerman (Aka The Naked Physio) about Clinicians Getting Creative.  He presented a series of creative and sometimes artistic images and tools that might be used to help practitioners to help patients come to a deeper understanding about their pain.  Many of them served as a great springboard for discussion and others were sure to be shared by clinicians for use in the clinic on Monday.

Robert Sapolsky was engaging and witty.  Having recently crammed his book “Why Zebras Don’t Get Ulcers”, much of the material was familiar, however I found his endearing stage presence did much to dissipate my stressful reaction to the material –which is largely about how stress is so damaging to many systems in the body!   Immediately following him was  Fabrizio Benedetti who spoke about how placebo works at a neural level, in situations of pain, Parkinsons Disease and physical exertion.  Largely they tend to activate the exact same pathways that specific drugs do, to provide improvements – somewhat obvious when pondered more deeply, and yet something I hadn’t thought to think about!  It brought up many thoughts and questions for me regarding the clinical benefits of this that aren’t currently being used and other questions about ethical issues in this area.

Kevin Vowles, who I have written previously about here, spoke of ACT and its use and efficacy in the treatment of persisting pain.  He says that the literature tells us that for patients who have persistent pain, it is unlikely that any modality will be able to significantly reduce pain scores.  With this in mind, he advocates helping the patient to take the focus off the struggle to reduce their pain and emphasizes trying to live a valued and meaningful life in the presence of pain.  (I have written about ACT in the clinic here) It was a fantastic refresher and he is a charming and charismatic speaker.  I can highly recommend his courses.

Other highlights of the summit were Bronnie Lennox Thompson, whose gentle dulcet tones could lull anyone into changing their behaviour, speaking about motivational interviewing techniques.  The verbal sparring between Todd Hargrove and Greg Lehman provided much entertainment, but equally their presentations were both fantastic and endeared attendees to look further into their blogs and courses.  Sandy Hilton gave great insight into how structuring not just your language and treatment can help a patient to relax to better engage with treatment, but even how arranging your furniture and clinic set up can help put patients at ease and create a relaxing environment.

The Summit provides an opportunity for clinicians to come together and strengthen ties that are desperately needed. In order for us to keep moving forward as a community to help the healthcare industry adopt  a clinical approach to treating pain that fits with our modern understanding of pain science, we need to make sure that our “team” is as strong and focused as possible.  Plus a bit of sunshine doesn’t hurt!

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Be sure to keep an eye out for the podcast by Karen Litzy from Healthy, Wealthy and Smart which was recorded at the event.

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Karen Litzy and I get our selfie on

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Out to lunch with Joletta Belton from MyCuppaJo

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Antipodeans represent! Bronnie Lennox Thompson and Paul Lagerman

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I presented on Cognitive behavioural therapy and its use in the treatment of chronic pain

What can we learn from anti-vaxxers? How to change a person’s mind.

Painiacs, like myself, can feel at times like the process of getting practitioners to reduce reliance on reductionist approaches and adopt (even slightly) a more biopsychosocial approach when dealing with patients, is a massive uphill battle.  The fact that you are reading this blog suggests that you are probably most of the way there – but how do we engage those practitioners who are most in need of the “paradigm shift” required for society to be able to approach pain with a better understanding of the evidence about pain?

Social media has become an incredibly powerful medium for information to be spread far and wide.  So whilst things might appear to us to be slow, you can imagine how much harder and slower it would be without the internet.  We are able to get our hands on far more content than ever before, share ideas, discuss approaches, debate opinions – put together these can help us to view different parameters of our practice in the light of an informed mind.

One of the problems with the internet is, our searching tends to confirm our own biases for the vast majority of the time.  Which if you are hoping to expand the depth of your knowledge on a particular topic can be very helpful – forums can help with different resources, and others opinions can help guide your discoveries.  But what happens if your initial inkilings about a subject lead you down a dangerous and ill informed path?

I am fascinated (and at the same time furiously frustrated) with Anti-vaxxers.  What makes a person so convinced that Big Pharma are out to get us despite every bit of evidence telling us that vaccines are overwhelmingly safe?  That the risk of exposing their child to a dangerous and preventable disease is a better option than vaccination?  I ask this very genuinely – I have no doubt that they are looking out for their child’s health.  My curiosity is surrounding how the situation comes about in the first place – because we know that once people strongly hold these views, getting them to change their mind is nearly impossible.  In fact, using techniques such as delivering information that demonstrates the lack of a link between vaccines and autism, or about the dangers of vaccine preventable diseases, can actually make people dig their heals in even more! ( See the article here)   (A subsequent study found that highlighting factual information about the dangers of diseases such as measles, particularly with the use of pictures and descriptions of children infected with the disease, had slightly better success).

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In some ways it is understandable – there have been times in the past where government bodies have got it wrong in making recommendations for the public, and plenty of examples of where commercial interests play a big role in influencing public policy and recommendations even in the face of significant evidence that flies in the face of such recommendations – (see this fantastic podcast by Dr Norman Swan on the ABC Health Report reviewing  both commercial and pharmaceutical influences in the calcium and vitamin D public recommendations).  Perhaps hearing about these situations, the potential anti-vaxxer starts to see conspiracies everywhere and feels the need to seek “the hidden truth”.  Dr Patrick Stokes,  a senior lecturer in Philosophy at Deakin University eloquently  laid out how this can be taken one step further:

“Antivax belief may play on the basic human fears of hesitant parents but the specific contents of those beliefs don’t come out of nowhere. Much of it emerges from what sociologists have called the “cultic milieu” – a cultural space that trades in “forbidden” or “suppressed” knowledge. This milieu is held together by a common rejection of orthodoxy for the sake of rejecting orthodoxy. Believe whatever you want – so long as it’s not what the “mainstream” believes.

This sort of epistemic contrarianism might make you feel superior to the “sheeple”, the unawake masses too gullible, thick or corrupted to see what’s really going on. It might also introduce you to a network of like-minded people who can act as a buffer from criticism. But it’s also a betrayal of the social basis of knowledge – our radical epistemic interdependency” ( You can find whole article here)

 

So, I guess that goes some way to explain how educated (yes, sometimes even very educated), middle class people in affluent suburbs (as that is the most accurate demographic picture of the “conscientious objector”) come around to thinking that not vaccinating their children is the correct choice.  There is probably an element of the entitlement culture creeping into the issue too – “Why should I do something to help out everybody else?”.  Throw in the odd distressing Chinese whispered story about the kid whose autism kicked in right after the MMR needle and I can begin to see how it comes about.  It doesn’t make the situation any better though! (For those of you who don’t know, Australia has just introduced a ‘No Jab, No Play’ legislation change which is likely to vastly drop the number of conscientious objectors via financial disincentives.  You can read more about this topic  on this blog.

So what is the link to pain science?  It’s the digging in of the heels situation – knowing that once people have settled on an opinion that suits their understanding, fits with their biases and pays their bills, getting them to change their mind about their approach can be difficult.  Pushing too hard in the “wrong” direction can have the opposite effect to what we are hoping to achieve.  When formulating  a  message, it probably needs to be carefully worded so that it doesn’t throw the baby out with the bath water – you can keep your trigger points, dry needling, manipulation, ouchy tool massage, strict order based therapy protocols, pilates…….  whatever single modality floats your boat and pays the bills – you probably just need to frame that intervention accurately to the patient and use it as part of bigger picture approach that places a great deal of emphasis on working towards self efficacy.