Blog 7: Making a mountain out of a ‘pain’ hill

Making a mountain out of a mole ‘pain’ hill.

I often use the metaphor of a ‘pain hill’ when I am describing what is needed to be done to improve and achieve a ‘normal’ degree of protective pain again. And because I have the sort of mind that keeps making weird connections, I often think to myself of things like song lyrics to further metaphorise (I think I just made up that word) my metaphor.

So who better than the ‘king’, and in his most excellent gospel style. The song I am thinking of is a haunting one that can be seen and listened to on You Tube via this link:

 

The chorus lyrics:

♫  ♪  “But this time, lord you gave me a mountain
A mountain you know I may never climb
It isn’t just a hill any longer
You gave me a mountain this time.
♫  ♪

These words are rather dramatic but apply at various points in injury rehabilitation and always in persistent pain. The hill can really seem like a mountain that can’t be climbed.

But it still needs to be climbed; trying to go around it is not a reliable method and not going over it means you are stuck on the wrong side.

With chronic pain, the idea is to first understand pain comprehensively then start up the hill confidently with exercises and re-gaining fitness. It is important to choose a slope up that mountain that suits your particular situation. Originally, I used to advise people in pain that if they chose a slope too steep it could result in too much pain and the risk of sliding back down the slope was higher. However, I have altered my original views based on my own observations and an interesting program I have discovered*. The reality is that once actual structural harm to the body is taken out of the equation, those who choose a steeper slope actually do better overall and recover more quickly despite the initial pain! Standard rehabilitation exercises provided along with normalising everyday activities do not logically represent harm; there is only ‘perception of harm’ which is precisely the reason why the pain is persisting in the first place.

However, as stated, the steepness of the slope up the pain mountain has to suit the individual’s particular preferences because ‘perception IS everything’. Whatever method is chosen, steep or more gradual, what is needed is to take steps forward and upwards to the top of the mountain and then the easier downward slope to recovery can be reached.

Exercise programs are a component of current pain management programs but there is all too often still  inadequate confidence due to a continued focus on faulty structures that are seen on scans that have very little real, if any, significance. The message often then given is ‘learn to live with your pain, but do these exercises as they will help you’. Therefore the perception of ‘danger’ can easily still exceed the perception of ‘safety’ increasing the pain slope again. Whoooa, there I go, back to the bottom again – fix me doc … please!!

But, the major point of this blog is to point out how easily the same process can apply to critical points in standard injury rehab programs. This then sets the stage for a persistent pain outcome. And to illustrate this point, I will relate a personal anecdote.

My youngest daughter was playing netball one night as a 16 year old. I received a call saying that she had “dislocated her knee” and figured out fairly quickly that this was a patella (kneecap) dislocation. I arrived at the court about 20 minutes later and my daughter had ‘frozen’ with fear and pain. I distracted her and gave the patella a push back into place. There was the anticipated scream, then tears, then relief. I took my daughter home and applied the treatment basics over the first few days, then the next few weeks, then over the next few months. No x-ray, no scan; just clinical assessment and monitoring responses to increased loads etc. I have just cut a long story short because this is not the important part of the anecdote.

It wasn’t easy and there were a few times when my daughter’s apprehension needed much encouragement and gentle coercion, but eventually she regained excellent functional control and powerful distal quadriceps (muscles around the kneecap) tone. She returned to netball at the end of that season for a few games and then played out the next season, continuing her high level exercises with dad annoying her frequently, as dads do.

The season afterwards she travelled in a different sporting direction and focussed on ‘cheer’ which is becoming very popular. To my mind, I thought that the physical requirements weren’t quite so demanding as netball, so I got ‘off her back’. As is probably typical among teenagers, she admitted later that she had slackened off on her program substantially.

While visiting Tasmania with my wife (isn’t that MONA place weird??!) earlier this year, and just before leaving for dinner one night, a phone call was received from Melbourne advising that a rather vigorous cheer manouvre went wrong and the patella was out again. My then 18 year old daughter froze again due to fear of pain. My telephone recommendation to give it a quick push or simply straighten the knee went unheeded. Dad was a plane trip away this time and so the patella was finally relocated over an hour later after transfer to a local ED and a bit of sedation, then crutches, zimmer knee splint, recommendation to see an orthopaedic surgeon etc…

I oversaw a similar injury treatment program over the initial period including discarding the splint and early isometric (contraction alone) distal quadriceps contractions, but at about two weeks I started getting worried. The pain apprehension was worse this time and there was no ability to do the simple exercises, let alone any others.

To scan, or not to scan, that was the question.

Prior to doing this, we both sat on the carpeted floor one night (approx 3 weeks post injury) and I must have spent about 2 hours trying everything I could think of to get her muscles ‘activated’. There were tears and fears, half attempts, pain complaints and early fatigue. We took regular rest breaks, and then started again. The focus was on the quality not the quantity but we weren’t getting much of either for a long time. But then it started to happen – the kneecap started to move up and down and the very wasted quadriceps muscles around it started to wake from slumber. We continued until I really felt she had it sorted out reasonably and then repeated the process over the next few days focussing on the quality and varying the speed of the muscle contractions.

That was the turning point.

The effusion (knee fluid) settled proportionally as the function and strength was regained. Further rehab progressions, VMO focus (muscle on the inside of the kneecap which helps it stabilise), bike, higher intensity exercises, plyometrics etc… Full range of movement regained. no fluid responses to increased load; all coming good. No need for a scan. Functional stability gained again with the help of a nagging dad.

She returned to cheer with lots of high intensity exercises in addition to her training and a careful but vigorous warm-up routine. I watched her just today on her 19th birthday at a national cheer competition and she was easy to pick out from a distance because she was wearing a black patella stabilising brace (only used during high demand activity). Her team came second out of seven teams in that section. I think she will now do her ongoing functional stability program more diligently because there may not be too many more chances. I will still annoy her frequently though, just in case. That’s my job as a dad anyway.

I have never been impressed with the results of surgical pathways in recurrent patella dislocation patients. Interestingly a friend of my daughter followed such a path, had several operations with a poor outcome and this helped convinced my girl to stick with the plan.

She had quite a few hills to go over in her rehab on both occasions that eluded being described in this blog to shorten it. But that night on the floor, she faced a pain ‘mountain’, and we went over it together.

The difficulty of that process impressed me.

There are probably many similar mountains faced in injury rehab situations where the perception of danger continues to exceed the perception of safety.

And rather than go over the mountain, the limited time and available patience for patients in current practices leads to an expedient scan, a surgery referral, higher doses of painkillers and a ‘fix me doc’ pathway. Not only is the mountain not climbed but the road that led to the mountain is travelled backwards again. And somehow the longer that mountain is there in the way, the larger it seems.

I don’t know the details of why Elvis Presley developed chronic pain which apparently led to a fatal medication dependency. Perhaps he tried to go around the mountain instead of over it.

PS: From today’s competition:

IMG_1571

 

*”Boot Camp” – Chapter 13 in the book Watch Your Back by Richard A Deyo MD. Cornell University Press. Dr Deyo is renowned for his excellent widely published research in the massive first world problem which is back pain. I highly recommend this book which is available online.

Deyo

Blog 6: The ZOO in the room

A while ago I was inspired enough to write a comment on an article in the Australian Doctor website by a Jane Hall who is professor of Health Economics at the University of Sydney –

OzDoc

Medicare review must deal with ‘elephant in the room’ incentives.

You can hopefully still access this article if you click this title.

The article discussed aspects of the Medicare Benefits review initiated in recent times. It brought up the problem that the reviewers may “fail in their task unless they deal with the incentives to over-treat created by our fee-for-service system”.

It even concluded with the following including a direct mention of relevance in pain management:

“Then there’s the issue of the threshold for investigation or treatment. Take pain, for example: how much of it is serious enough to warrant an MRI? The point we’re trying to make here is that it’s rare that an indication or symptom is clear and without room for discretion.

And that leads to the elephant in the room that the reviewers have to deal with if they’re going to be successful.

Our health system is based on a fee-for-service model, so every time a doctor provides a service, the government pays a fee via Medicare. This means the more services provided, the higher the provider’s income. Not surprisingly, this unintentionally encourages increasing volume but not necessarily appropriateness (the right treatment for the patient) or quality.

Of course, this doesn’t mean patients are not treated well or that doctors don’t provide good quality care. But the incentives in the system are not well aligned with delivering the most efficient care.

Ensuring that what’s good for the patient and good for the future of Medicare is also good for medical business is really the only long-term fix for a better health system. We’ve long talked about making healthy choices the easy choices for consumers, now it’s time to focus on making efficient choices easy choices for health service providers.

This review is an indication of a more considered and consultative approach to formulating health policy. But let’s not forget that it’s the incentives that matter.

And this was my comment:

“The elephant is certainly in the room. The room also contains a flock of ostriches (with their heads in the sand), a dinosaur Medicare schedule, and people who still prefer to think the earth is flat.

Plain and simple – in the current system it is far easier, less time consuming and exceedingly more profitable to ‘intervene’ than to ‘educate’.

This is particularly pertinent to the management of musculoskeletal pain as mentioned briefly in the article. What a curious observation it is that, based on available data, the period over past decades with expensive major advances in investigation and therapeutic options, technology, interventional and surgical expertise etc, coincides rather uncomfortably with a significant increase in chronic musculoskeletal pain outcomes in the same time period. Persistent pain is associated with tragic outcomes for patients and their families and has major health expenditure ramifications. So not only is the budget straining with the funding of these tempting technologies and interventions, but it then is forced into the red further by the expenses associated with contentiously effective and increasingly common ‘pain management’ requirements. Curiously again these are also disproportionately interventionally focussed.

Patients in pain are scanned expensively and repeatedly. There is almost always some sort of degenerative finding discovered which is speculated and then informed as causative even though these are found abundantly in asymptomatic screening. Then, an expensive pathway ensues with low level evidence for most musculoskeletal & orthopaedic interventions and surgeries. This is despite questionable real outcomes beyond placebo construct responses (NB: sham comparison research trials on knee arthroscopy). In common spine pain, the expensive negative outcome consequences of this accepted process are becoming increasingly recognised. Persistent pain patients who have undergone spinal surgery in their pathway are a well-represented number even meriting their own special named syndrome …

Explaining pain carefully and properly is crucial to facilitate recovery via neuroscience education, reassurance, proper perspective and self-management. This is usually much more appropriate ‘treatment’, yet more difficult, and does not attract the lucrative rewards associated with interventions and surgery. To explain pain, it first needs to be understood by the practitioner, who is more readily seduced by procedures and interventions than exploring quality pain education both for themselves and for their patients. The existing financial incentives, either consciously or subconsciously, influence practitioners to offer interventions to desperate patients as ‘fixes’. Furthermore, in justification, scientifically unworthy ‘flat-earth’ conclusions emanate from selected poor quality research as firm support for these methods accompanied by avid marketing techniques.

Perverse incentives encourage disempowering vulnerable patients.

Supply, rather than demand, dictates provision of services.

Paradoxically, it was Paul Keating, who in addition to committing to the servicing incentives fashioned by Medicare, apparently was also quoted as saying -”In the race of life, always back self-interest – at least you know it’s trying”.

I was dark wasn’t I !!

I must have had a particularly frustrating case to review at work that day.

No wonder I received this comment in reply from someone identified as Wow – well said – I think. It’s going to take me some time to digest all that …”

And then I found a like minded (and much easier to understand!) comment as a letter in The Age newspaper that indicates that there are at least two medicos who think alike; hopefully more:

Best to click on it to see it better-

LetterAge

It is interesting that Dr Cheng uses the examples of antibiotics and scans in back pain as I have in my first blog.

Blog 5: Pain is SUCH a pain!!

Persistent pain just isn’t sexy.

For one thing just ask patients with the problem.

If you have almost any other medical condition the sympathy and support around you is more often than not long lasting and uncompromising.

I see  a substantial number of persistent pain patients and there is a very common feature among almost all of them and that is the breakdown of their domestic and social support systems.

It appears that when it comes to persistent pain, many of those we love and befriend have limited patience and understanding. In that sense you are probably better off having diabetes or something similar.

I have observed that this is even a problem in cases of severe injury, so imagine if you are one of the poor sods who has very little on your scans to ‘justify’ your pain.

This support system breakdown feeds into pain persistence and amplification because it creates more psychosocial distress and a feeling of having to justify oneself. This results in more desperate attempts to seek pain ‘cures’, more surgery etc and … more pain.

I can provide so many examples but the two that come foremost to mind are recent cases. One case is of a worker who suffered a simple lifting injury as a regular 27 year old resulting in the usual management and surgery merry-go-round. Cutting a VERY long story short he became an opiate addict and died because of an opiate related complication in his early 50s. No one notified his case managers of this person’s death until I discovered it in a chat with his GP many months later. Now that may  not sound unusual but usually when workers die as a complication of their injuries / management problems there are entitlements to the family which are pursued. The GP confirmed that this poor fellow died alone without family or friends. As a result of a simple lifting injury in his 20s. Shame he didn’t hurt his back playing footy or cricket instead.

The second example is that of a young patient who I saw just yesterday. A fit looking and intelligent fellow in his 30s who has had several work related back pain episodes and 3 back surgeries which were structurally successful and performed by eminent surgeons, yet his pain is severe, persistent and resistant to medication etc. He had overt pain sensitisation features and I strongly suspect his pain was not reliably generated from a structural target amenable to being ‘fixed’ from an early stage in his pathway. His eyes welled up with deserved tears as he advised me that his partner and soon to be born child were in the process of leaving him as a result of his pain and pain related disability.

But enough of sad patient stories. Pain is not particularly popular in other ways as well.

The epidemiology (population health statistics) of chronic pain and especially spine pain is simply staggering and seems to be a peculiarly more prevalent problem in Western Societies. In terms of cost to our community the figures are scary. It seems that only those making money in this field are consistently benefiting, and benefiting substantially*. The overwhelming focus is on expensive programs, pharmaceuticals and interventions. The outcomes are no better statistically than what would be expected from a weak placebo construct effect; overall we are not really making any meaningful progress as from what I can gather only the rate of increase in numbers of persistent pain cases has slowed, not the trend itself. As mentioned so many times on this site the very basic and relatively inexpensive measure of optimising pain literacy in patients and practitioners alike is nowhere near a high enough priority. This has to include the confronting recognition of the fundamental flaws of the management model that has been accepted for too long, or it is essentially useless. That is something that too few are prepared to do.

As yet, media attention to chronic pain is not high. In recent times media attention has been increasingly directed at the health system with respect to ineffective management and similar, but the progression to chronic pain outcomes has not really been explored to any meaningful extent. Quite the contrary, all the popular media attention that I have seen in recent times in chronic pain seems to be towards the next touted ‘miracle cure’.

The interests of various stakeholders including influential expert health practitioners seems to predominate the concerns of those in influence.

Now imagine if persistent pain was an influenza epidemic or, for the sake of more dramatic effect suiting my blog – EBOLA! And it affected over 20% of the community (as it does)!

I’m confident a task force would be created and every basic measure would be taken care of meticulously. Ineffective management would soon be exposed and ceased. And the only stakeholders considered as priorities for attention would be the patient and the exposed community. That would be a real perceived crisis and imagine the media attention!

Ok, I hear you saying that I am being ridiculous – chronic pain doesn’t cause such dramatic demise and kill like these illnesses. And I agree on that point. However, I am confident in my proposal that the health, social and economic effects of chronic pain are substantial and from the statistics most recently available, including a Lancet study**, at least comparable in many ways.

Finally, and perhaps most frustratingly for me at present, is that persistent pain patients themselves, and pain discussions beyond simplistic structural terms, are simply not popular among my colleagues. I quite definitely detect an ‘eyes glazing over’ moment in most discussions. My ego tells me that it is not because of the way I deliver the message (it probably is, but don’t tell my ego!), but there is no doubt that the patience for this discussion which now so fascinates me, is limited.

Examples and points of interest:

  1. I am VERY keen that the ‘language’ when describing pain in discussions on patients needs to be accurate. I think this is a basic measure of vital importance in the pursuit of proper pain literacy and better outcomes. At a recent professional review group meeting (Continuing Medical Education activity) with about 8 experienced sports med physicians, I was summarily derided by one who stated something along the lines of “Kal, we always wonder how long it will be until you bring up NOCICEPTION again!”
  2. It is important to contrast this with the enthusiasm at such meetings with which any new potential pharmacy and interventional treatments are received no matter how bizarre and thinly evidenced. That is of course until later on when the wave of enthusiasm is heading back out to sea and then we start to criticise those who are persisting in profiting from these products eg: ‘regenerative’ injection treatments, that seem to provide similar disappointing rates of success comparable to other modalities and … placebo.
  3. It is also worth contrasting with how much of these and other meetings are occupied with discussion of the management of structural findings in patients with pain. I think there is no need to elaborate on this point.
  4. Just mention chronic pain patients to most doctors and if you are really attentive you will notice either a ‘sigh’, a ‘rolling of the eyes’ or ‘shrug of the shoulder’ despondence. You will certainly detect a reluctance to engage meaningfully as it is just too taxing and difficult. Mind you that is most often after the ‘dartboard’ method of management has taken place for some time. That is fun until you get to the point where nothing is working and then many just want these patients to leave their offices as soon as possible. Perhaps that is why so many are given another prescription, another investigation request form or a referral to someone else who is rolling their eyes as well …
  5. NB MY EMBARRASSED CONFESSION: To be completely honest up until recent times, I too stood guilty as charged:

Just ask my wife. Like my sports medicine colleagues my interest was in treating structural flaws. I would come home frustrated after many sessions at which the usual procession of persistent pain patients with widespread problems that didn’t ‘fit the mould’ would parade through my door one after the other. I would state repeatedly to my wife – “there must be a full moon out tonight”. I am now too embarrassed to explain that comment if you don’t actually get was I was inferring.

Because my own pain literacy was woefully inadequate, I similarly considered such judgmental, derogatory and unhelpful terminology such as “abnormal illness behaviour”, “functional overlay”, “non-organic pain”, “secondary gain” etc…

It wasn’t my treatment that was the problem, as like others I interpreted my successes as a vindication of my skills (see blog 4). It was my patients’ faults for not responding the way they should!

Having made this confession, I can direct you again to my very patient, wonderful wife and much loved partner of 28 years (who is also my blog editor!) who will no doubt attest to my more recent unqualified enthusiasm with my work. These days I am still managing injuries with sports and exercise medicine knowledge when appropriate (and also more holistically). I see even more of the usual sad parade of persistent pain patients. However, I am managing them with a much better understanding of what is going on and what has brought these people to this point. My pain literacy, empowerment and ‘normalisation’ program is embryonic but producing very encouraging, and occasionally startling results; most importantly, with no harms attached.

Having achieved a level of better pain literacy for myself has been liberating.

Viewing these unfortunate patients now with different eyes is nothing short of fascinating.

Drawing the connections with them is a challenging and confronting process, and is far from easy. It has been substantially more professionally rewarding than my “full moon” period.

In the current phase of my career, in my clinical practice, and including my attempts to spread the word educationally, I can wholeheartedly state that ‘PAIN IS NO LONGER … A PAIN!!’.

* Pain Medicine Versus Pain Management: Ethical Dilemmas Created by Contemporary Medicine and Business. Loeser and Cahana. Clin J Pain 2013;29:311–316. Synopsis available via:  http://www.therehabcenter.com/documents/SpringSpecialEdition_001.pdf

** Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. www.thelancet.com   Published online June 8, 2015 and available via: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561509/

Blog no 4: “He (or she) done it!”

Please contemplate the following metaphorical imagery:

windows2

‘What is he on about now’, I hear you say.

The image on the left is a view from a downstairs window and is idyllic.

The image on the right is a view from a top storey window looking down over a rather polluted and dingy city.

The message I am trying to convey in relation to persistent pain is an indelible impression I keep having on a recurring basis as a result of my (over 2000) detailed compensation case reviews. Actually these case reviews are remarkably similar in many ways; I often quip that they are like movie scripts with similar plots and endings, but just different names in the rolling credits.

People get injured, or simply develop pain with no actual trauma as such, and their journey begins through the medical / surgical management process. They undergo the usual investigations and various doctors, therapists and surgeons get involved.

And here it is – almost all treating practitioners think that they on the whole are doing a great job. Almost all believe that the responses to their interventions are positive and successful. And much as I am reticent to point fingers, I feel compelled to indicate that surgeons are over-represented in this observation.

The view ‘from a higher floor’ of the entire case and clinical pathway is consistently nowhere near as idyllic a scene as the view from a single downstairs window.

Now, everyone seems to acknowledge the undeniable statistics that persistent pain has increased remarkably over recent decades in Western Society despite modern health systems, and post-surgical persistent pain is a large part. So if everyone is doing such a good job, how come this is the case?

Furthermore, when I discuss this topic with various practitioners, they blow their own horns happily and usually blame others for poor management processes –

ie: ‘he (or she) done it!!’

Like in the school yard … remember?

In fact, it  has been my overwhelming observation as a medico that the health professions in general are actually quite proficient at blaming others within and without for all sorts of problems and poor outcomes. Medicos slag (sorry – criticise) each other quite often and with little provocation. And then this extends easily to other non-medical craft groups.

In particular, my conversations with surgeons about poor outcomes are almost always accompanied by confident assertions that their outcomes are excellent with happy patients and that the bad results are being achieved by others less capable.

But everyone seems to say the same thing … including me!

It is a bit like the thing that patients always say about having a ‘high pain threshold’; I am yet to hear anyone who admits to having a ‘low’ pain threshold. (NB: actually when one understands pain neuroscience properly this statement becomes so much more interesting!)

Very commonly, I have documented cases when a post-operative review reports positive and sometimes even excellent results virtually simultaneously with other records and other examination reports reporting very poor outcomes.

And few, if any, do proper audits.

And when, audits / studies are done they are based on ‘patient reported outcomes’.

I wish I had $10 (inflation has hit because the expression used to be $1) for every time I have personally assessed or case reviewed patients who perceive their surgery very positively yet every objective parameter depicts precisely the opposite. They seek more surgery. A recent case I recall was a poor fellow who had two cervical spine surgeries over several years and was upset that his third (extending his fusion above and below the several levels already fused for similar degenerative changes) had been denied for payment by his insurer. This fellow had never achieved any meaningful return to function and was on a morphine equivalent of over 200mg per day  (??! – IMAGINE BEING HIS ANAETHETIST AND MANAGING HIS POST-OP ANALGESIA!)  with minimal effect. But he quite confidently told me that his surgeries were successful and he was keen to have another. His pain sensitisation was off-the-scale as I couldn’t even touch him and he could barely move, but his surgeon was keen to have another go. I am confident this fellow would have ticked the positive box in the ‘patient reported outcome’ form in a study and rated his surgeries highly; this is what he told me directly was his perception.

I wonder whether many simply do not want to invalidate their own poor decision making and/or are not keen to criticise their charismatic surgeons who offer hope … again and again and again.

Perhaps others have low ‘minimum acceptable outcomes’ and any relief no matter how temporary or minor is perceived positively.

I suspect most respond positively via a placebo construct.

At this point, I will remind all again of the game-changing research relevant to placebo controlled surgical trials in eg: knee arthroscopy.

FINALLY, surgery is being subjected to the same rigorous research process as medications ie: via placebo / sham / fake  surgery comparison controlled trials. What this has importantly discovered in knee arthroscopy surgery is the following – a very widely performed procedure with almost unequivocally positive outcome studies based on patient reported outcomes (PROs), and with minor complication rates, is now highly questionable if not completely debunked.

I think it is a fair observation that patient reported outcome results in spine surgery are not as positive and uniform as those seen in knee arthroscopy trials and there is a significantly higher complication and persistent pain outcome rate.

To my way of thinking this extrapolates easily into a mandatory requirement for serious interrogation and re-interpretation of the existing supportive ‘best available’ data and accepted research methods for spine / other surgery interventions for pain. PRO studies of various quality are consistently presented as robust ‘evidence’ in support of surgical pathways despite poor support in systematic reviews. The same people who confidently present such data heartily criticise other less harmful craft groups, eg: chiropractors, who present similar methodology with patient reported outcomes and comparative treatment research.

But, as I was advised recently by an eminent spinal surgeon on this topic, who was very confident of his own non-audited results and was quite critical of other less experienced or proficient surgeons bringing the profession into disrepute (‘they done it!!’), “everyone knew that about knees, but spines are different … !!”

References to consider include:

  • Spine surgery outcomes in a workers’ compensation cohort – Harris et al. ANZ J Surg 82 (2012) 625–629
  • The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Jacobs et al. Eur Spine J. 2013 Sep;22(9):1936-49
  • Epidemiology chronic pain. Croft et al. 2010 (Oxford University Press)
  • Failed back (surgery) syndrome: time for a paradigm shift. Vleggert-Lankamp et al. British Journal of Pain. Feb 20, 2013
  • Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. Thorlund et al. BMJ 2015;350:h2747
  • Use of placebo controls in the evaluation of surgery: systematic review. Wartolowska et al. BMJ 2014;348:g3253 doi: 10.1136/bmj.g3253 (Published 21 May 2014)
  • Belief reinforcement: one reason why costs for low back pain have not decreased. Zusman. Journal of Multidisciplinary Healthcare 2013:6 197–204
  • Assessment of spine surgery outcomes: inconsistency of change amongst outcome measurements. Copay et al. The Spine Journal 10 (2010) 291–296
  • Bias in Surgical Research. Paradis. Annals of Surgery. 2008;248(2):180-188
  • Twenty-year perspective of randomized controlled trials for surgery of chronic nonspecific low back pain: citation bias and tangential knowledge. Andrade et al. Spine J. 2013 Nov;13(11):1698-704
  • Minimum acceptable outcomes after lumbar spinal fusion. Carrragee, Cheng. The Spine Journal 10 (2010) 313–320

 

PS: I wrote this blog last night. Just today I did a case review at work and to cut a very long story short here is some info and some exactly reproduced de-identified quotes:

The injury was due to simply straightening from a bent position in Sept 2011. Early MRI etc… And waddya know but the circumstance investigation report revealed that a bullying accusation had been lodged a few days previously with the employer. This finding was not noted by anyone else in the worker’s pathway.

Context versus ‘pathology’.

Surgeon IME (independent Med Examiner) October 2011: “I do not recommend any change to the worker’s current treatment. I believe that because of the pre-existing degenerative disease and also his functional response to my examination, it is likely that he would have prolonged symptoms irrespective of the type of treatment he received. The surgical treatment recommended by xxxxx is reasonable and appropriate. However, I feel that it is likely that he will continue to have symptoms even after an apparently successful operation …”

The worker had had no specific pre-operative conservative management apart from rest, investigation and analgesia.

Surgery was then done in November 2011 (NB: approx 2 months post onset of pain) in form of L5/S1 instrumented fusion etc despite highly discordant clinical features, no objective radiculopathy and relatively minor MRI changes; certainly no overt neurocompression was reported, only ‘contact’.

Occupational Physician IME May 2012: “Postoperatively, Mr XX stated he has been troubled by ongoing pain in his back and down the right leg …” . There was no mention of a period of relief and there was  no functional recovery in this 6 month post-op period. Strong analgesia requirements continued.

Medical report from Surgeon May 2013: “The indication for the surgery was L5-S1 spinal stenosis. He had an early excellent response to the surgery with resolution of previously intractable right sided sciatica, however despite good initial progress unfortunately his right sided leg symptoms subsequently recurred at 4-6 months postoperatively …”

Definitely an excellent result.

window

I think you can imagine how this worker is doing now in 2015 –

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Blog 3: “Sorry, but there are SO many more than 50 shades of grey in pain”

Medical experts love getting together and negotiating consensus positions for diagnostic and treatment guidelines and definitions. For example you are considered to have persistent (previously known as chronic) pain when you pass the three month mark from the onset by the official consensus-reached-by-many-experts conclusion. Furthermore you are entitled to ‘normal’ pain due to proportionate nociceptive (electrical signalling) stimulus in the early injury phase always, and there is no reason to have any concern unless that pain persists.

ie- like this lovely commonly used graph picture:

(It is easier to see the details if you click on it)

New Picture

I suppose this makes practical sense, for example  so that epidemiologists (researchers in health statistics) can analyse things.

The actual guidelines are more intricate if you read them carefully ie via: http://www.apsoc.org.au/PDF/Position_Paper/apa_position_statement.pdf but I can tell you from multiple conversations with a biomedical model obsessed therapeutic community that there is a problem. What is actually practically remembered by most is that somehow maladaptive pain is only really a consideration after 3 months and even after that the scan changes seem to dominate anyway until everyone gives up on ‘fixing’ things a long way down the track.

What inevitably happens is that people then think the consensus derived definition is sacrosanct and direct more energy into defending the definition and pigeon-holing people into it than managing the actual highly complex situation in front of them.

Now let me show you how easily this approach comes unstuck.

Let’s keep on track and consider that lovely graph above. (Again, it is easier to see the details if you click on it)

Graph2

Keep the thought of those red and yellow lines running perfectly together in the early phase following “the moment of injury” and now have a look at what I call – “A tale of two nails”.

A tale of two nails – ‘Perception is everything’

nails

Reference: A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology. Joel E. Dimsdale, MD and Robert Dantzer, DVM, PHD. Psychosom Med. 2007 December; 69(9): 850–854:“Two brief case reports involving construction injuries with nails demonstrate the phenomenon beautifully. In one report (6), Fisher et al. described the case of a builder who jumped down onto a 7-inch nail, which pierced his boot at the toe level (Figure 1, left panel). The man was in pain and required intravenous sedation in the emergency room. However, when the boot was cut away, it turned out that the nail had fortunately passed between his toes as opposed to its apparent impaling of the foot. The man’s agonizing pain was elicited solely by his misperception—a case of somatic amplification. On the other hand, a report in USA Today described a construction worker who had unknowingly shot himself in the head with a nail gun (Figure 1, right panel) and who was unaware of the injury. He perceived a toothache and went to a dentist 6 days later, wherein the cause of the rogue toothache was discovered. In this case, one would conclude that somatic deamplification was at work. The patient was unaware of the injury and attributed the sensation to more familiar sources.”

In plain speak all this translates to the first dude thinking he was injured and having severe pain until he realised he wasn’t actually injured and the second dude being injured but because he wasn’t aware that anything happened, he generated no acute pain response.

This makes a bit of a mess of the lovely early bit of the graph, doesn’t it?

Another lovely example of this is Lorimer Moseley’s ‘snake bite’ story (check out the you tube video directly or via the ‘For Patients’ page on my website if you haven’t been to one of his lectures yet).

So, you may be saying – Why is this important? Why can’t I have my lovely little graph and definitions? Why are you making my professional life so difficult? Please go away and leave me alone!

The problem is this – firm adherence to linear definitions in what we know is the extraordinarily complex and multi-factorial construct of PAIN is in itself a contradiction in terms. The biomedical model view is based on a fundamental flaw which is the absence of a linear relationship between structural changes and pain. I urge the pain fraternity not to inadvertently make the same fundamental error. NB: People rarely read the fine print, so the message has to be very clear. The pain is either positively adaptive or negatively maladaptive and the earlier that is considered perhaps the better, albeit being cautious not to miss any ‘red flags’.

A practical example of this problem is a conversation had recently with an eminent spinal surgeon who advocated earlier surgical intervention for back pain on the basis that he was trying to avoid the persistent pain ‘phase’ after 3 months!!

Practically this problem is also manifest so very commonly by cases that I am involved with in compensation reviews where the ‘punishment just doesn’t fit the crime’.

These cases regularly involve minor mechanisms of injury with extraordinary long term and tragic pain outcomes. These problems are even potentially cross generational and the flow on effects in terms of social breakdowns, costs to the health system etc, etc, etc are well known.

In fact, it is my regular observation that, paradoxically, those with more severe traumatic injuries seem to recover better (in the absence of an acquired brain injury component) than those with minor ‘eg: I tweaked my back’ type injuries. There is that contextual and motivational influence again …

In an alarmingly large number of cases the original mechanism of injury leading to persistent pain in a ‘someone to blame’ context is almost the equivalent pathophysiological trauma of being blown over by a feather. There is a stark contrast to similar and very much more severe trauma occurring in a sporting environment.

Now that is not to say that there is no electrical signalling input to a protective pain response at all, ever. That is not what I mean at all. I am sure that even in the first nail case above, the electrical signalling from the nail passing frighteningly close to the tissues was appropriate to create that protective response saying ”help!!’ It is just that it proved to be a maladaptive response right at the very start of the problem and luckily it could be proven objectively once the shoe was removed.

To conclude, please consider an analogy with the first nail case. Imagine the shoe to be the external body covering of the spine. Then imagine the nail to be the ‘tweak’ of sudden pain lifting, bending or similar in the back, stretching briefly those poor little previously well adapted nerve roots or similar. Imagine the same early protective pain response. Imagine further that instead of being able to take the shoe off and prove that there was no reason for alarm and further protective pain, someone told you that the nail was stuck in your foot, or in spinal terms, you have got a disc ‘bulge’ / ‘pars defects’ or ‘fractures’ / ‘spondylolisthesis’ / ‘instability’ (isn’t that a common one these days?) etc, etc, etc ………….

Actually, you don’t have to imagine this at all; it can be seen so very often.

Blog 2: “The extraordinarily different body structure of the compensation patient”

One of the most common comments you will hear in the orthopaedic world is –

“The results of management, various interventions and surgeries are much worse in patients with a compensable injury and that is the fault of the ‘SYSTEM’ “

It is safe to say that this comment is widely agreed and it is also well supported by actual research looking at outcomes in terms of improving pain, function etc in a meaningful and sustainable manner. The corollary of this is that other non-compensable, self-funded patients fare so much better with the same treatment.

And yet, despite compensation patients doing regularly so much worse, almost all practitioners will similarly declare –

“Do you expect me to treat my patients differently?! That would be just SO wrong!”

Now, let’s think about this.

All these patients get the same management which focusses highly on STRUCTURAL targets. The primary intention of manual treatments, injections, surgeries etc are all focussed on affecting a STRUCTURAL target ie: the possible nociceptive electrical signalling input to pain only (read my explanation document).

By this logic, it would therefore seem unavoidable to conclude that somehow magically, or by as yet undetected mechanisms, the actual biological STRUCTURE of compensable patients is either intrinsically different to other patients from the outset (unlikely) or somehow magically alters during the compensation process.

This is quite difficult to comprehend.

I have posed this concept regularly with a variety of practitioners managing compensable patients with persistent pain and pain related disability with various pharmacies and interventions. As yet I have received generally evasive responses or I have simply been misunderstood. I haven’t as yet received a response reflecting a logical alternative idea to consider.

As stated, typically, the problem is blamed on the ‘system’ which includes adversarial case management and  especially the delay in management because of having to get funding approvals. So this means that targeted structural changes possibly producing nociceptive electrical signalling input to pain are in fact changed by stress but also somehow by ‘timing’. But hang on a minute, back pain consensus guidelines (as well as many other pain conditions) favour patience and comprehensive conservative treatment that takes quite a while to complete rather than early surgery. And this generally works well overall. So does that mean that it is only once you decide that surgery is required that the time delay in having the surgery somehow alters the faulty structure from then on making it less responsive to interventional effects? Go figure that time could do that … it’s as if we go stale like bread, but somehow this only happens after we decide to have surgery.

The most common research cited supporting spinal surgery is the SPORT series of studies in the USA. Curiously this research also suggested that the poor compensation patient’s body structural input to pain was different as the improvements seen in general patients were not the same in the compensation group despite having the same treatment:

  • The Impact of Workers’ Compensation on Outcomes of Surgical and Non-operative Therapy for Patients with a Lumbar Disc Herniation SPORT. Atlas et al. Spine. 2010 January 1; 35(1): 89–97:

“Conclusion—Patients with a lumbar IDH improved substantially with both surgical and non-operative treatment. However, there was no added benefit associated with surgical treatment for patients with workers’ compensation at 2 years while those in the non-workers’ compensation group had significantly greater improvement with surgical treatment.”

And it doesn’t end there! Recent research looking at a “no fault” insurance system ie: the New Zealand Accident Compensation Corporation (ACC) which is a universal NO-FAULT system offering early treatment and salary reimbursement etc… (see the reference below which is hot off the press) somehow again mysteriously proves that ‘FAULT’ influenced surgeries to the spine fare comparatively quite poorly. So, if you have someone to blame then that alters your structure but if you don’t then your structural contributors to pain, that can be fixed by surgery, are the same as everyone else. Fascinating … Perhaps they operate earlier in NZ before they go stale. Perhaps all people with pain / back pain should have an early operation if the scan shows a structural change and then we would get even better results?!!

But wait … what do the ‘Choosing Wisely’ program and other back pain treatment consensus guidelines consistently advise?? I’m so confused.

Therefore, according to this model, I can only conclude that the compensation patient’s STRUCTURAL input to pain when they get injured, or simply develop maladaptive pain without trauma, is different or becomes (more) different with (more) time.

***********

ALTERNATIVELY –

The other explanation that seems so much more logical to me, and is so very consistent with my observations, is that it is definitely the CONTEXT of the injury / pain that is the overriding significant factor to the outcome including any interventions. Ie: the well researched ‘bio-psycho-social’ model is the robust model with proper consideration of pain neurobiology principles and placebo / nocebo expectation-based responses. At this point if you still haven’t read my explanation on the ‘for patients’ page of my website you definitely should.

Unfortunately, this perspective is very likely to be confronting to most health professionals. That is because it means that the compensable group do NOT have extraordinary structure at all; they are indeed the same as the rest of us (or the same as themselves when they have pain and there is no one to blame).

It also means that it is actually the non-compensable group who are almost certainly obtaining a higher placebo construct response* from the various commonly provided pharmacies and interventions including surgery that many ardently believe are so very effective.

Why? Because their context is usually so much better.

* Placebo controlled trials have long been the standard in assessing effectiveness of eg: medication. Surgery is finally being subjected to similar trials eg: knee arthroscopy surgery. That is not to say the surgery has no chance of being effective for pain / pain related disability, it is saying that it is being indirectly effective via a placebo construct. Unfortunately, this is not a pathway without significant harms, life-changing complications or simply persistent pain despite structurally successful surgery.

Additional specific references to consider in relation to this blog include:

  • The relationship between compensable status and long-term patient outcomes following orthopaedic trauma. Gabbe et al. MJA 2007; 187: 14–17

  • The Influence of No Fault Compensation on Functional Outcomes After Lumbar Spine Fusion. Montgomery, Cunningham, Robertson. Spine 2015 Jul 15;40(14):1140-7 (abstract available only so far)

  • Universal No Fault Compensation is associated with Improved Return to Work Rates in Spine Fusion. Manson et al. Spine 2015; Epub ahead of print (again only the abstract is available to me so far)
  • Spine surgery outcomes in a workers’ compensation cohort – Harris et al. ANZ J Surg 82 (2012) 625–629
  • Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study. Nguyen et al. Spine 15 February 2011 – Volume 36 – Issue 4 – p 320–331
  • Workers’ Compensation Status: Does It Affect Orthopaedic Surgery Outcomes? A Meta-Analysis. Moraes et al. www.plosone.org 1 December 2012. Volume 7 / Issue 12
  • Association Between Compensation Status and Outcome After Surgery. Harris et al. JAMA, April 6, 2005—Vol 293, No. 13
  • The Role of Emotional Health in Functional Outcomes after Orthopaedic Surgery: Extending the Biopsychosocial Model to Orthopaedics. AOA Critical Issues. Ayers et al. J Bone Joint Surg Am. Nov 6 2013
  • The role of perceived injustice in chronic pain and related references. Nov 2013 available via: http://www.bodyinmind.org/the-role-of-perceived-injustice-in-chronic-pain/
  • Use of placebo controls in the evaluation of surgery: systematic review. Wartolowska et al. BMJ 2014;348:g3253 doi: 10.1136/bmj.g3253 (Published 21 May 2014)

  • And another very more recent article “Association between compensation status and outcomes in spine surgery: a meta-analysis of 31 studies. Cheriyan et al. The Spine Journal 15 (2015) 2564–2573”, which concludes the following curious outcome proving my point again –

    “… Conclusions: There is a two-fold increase of an unsatisfactory outcome in compensated patients when compared with noncompensated patients in spine surgery. Further research investigating the possible etiology of this association is necessary.”

Blog 1: “What do the common cold and persistent pain have in common?”

Here it goes – the first instalment of my blog series. It is titled as above.

I took this photo the other day at my local train station on the way to work:

(It is easier to see the details if you click on it)

2015-07-16 08.27.15

It may be apparent by now that my brain works in strange ways but I couldn’t help seeing a connection between this sign and my work.

The medical profession has known all along that antibiotics are only effective against bacteria and not viruses and that there was no direct benefit and potential problems in terms of resistance in over-prescribing antibiotics.

Yet, like a large number of people, I was always prescribed antibiotics every time I got a bug when I was growing up. Feeling awful, the local GP visited (house calls, ha – remember those?), a 3.5 minute consultation with usually a cold stethoscope and always a prescription. And I remember feeling better afterwards every time! There it is, that good old placebo effect again.

And as a consequence of this as a general habit what happened next was that the public became understandably conditioned to thinking that every time they caught a cold or flu-like illness they required antibiotics as part of their treatment. I still hear my bike riding buddies say this regularly when they get ‘chesty’.

So to cut a long story short, here we are in 2015 facing the real threat of ‘super bugs’ and antibiotic resistance threatening to take us back to the horrific results of infections in the pre-antibiotic era unless some clever scientist can figure out a solution.

Now what has that got to do with persistent pain you say?

A dinosaur like me goes back to the pre ‘scan’ era where we had no MRIs to help us with our injury management. The 3 medical idioms in those days (I was told by a recent graduate that they still are being taught) were:

  1. First, do no harm.
  2. Treat the patient, not the x-ray (scan now)
  3. Only order an investigation if it changes your management.

Apart from ultrasound all investigations carried a radiation exposure issue and so especially in young footballers, we relied heavily on our clinical judgement.

And then MRI scans came along.

High quality imaging. Ability to visualise so many more structures etc, etc. And no radiation.

Let’s go crazy … and we did.

Fast forward to 2015.

Every patient who walks through my door, either expects a scan or already has them and gives them to me right after they walk in to my office and then they tell me the diagnosis based on the report. And how scary are those reports (and getting worse)! A perfect very recent example (Oh, I have so many …) was a scan of a local athlete’s hamstring injury with the following description:

“… There is disruption of the intra-muscular tendon rachis with retraction of the tendon to create a wavy serpiginous appearance. Furthermore, there is myofibril disruption with oedema and blood fluid products tracking into the torn muscle fibres …” It actually goes on and on like this but that is enough. MYOFIBRILS! Ha. And all this in the background of my own experience finally backed up by recent research that  scan changes in good old common hamstrings strains makes NO difference to management and return to play outcomes compared to clinical management alone **.

Actually, in this particular athlete her hamstring effectively self released. After excellent rehab she was asymptomatic and fully functional; she presented worried about her other side threatening to do similar.

Back to my point. Good old HISTORY and examination and sensible judgement is now taking a back seat in a long bus to scans.

And here is the kicker. Even when you want to manage a patient sensibly and holistically without a scan, they mostly look at you with a ‘you are an idiot’ look and seek a referral elsewhere.

Just as the general public have been conditioned to think that a cold will not get better without an antibiotic they also have been emphatically conditioned to think that a scan is a vital part of the management of almost any injury or pain condition.

Furthermore, given the propensity of such scans to find things, the next conditioned thought is that what is found needs to be fixed!

Then even if one practitioner says that a procedure is unnecessary, there is always someone else who will offer that and more.

I recall several recent conversations with a few surgeons who, like me, said that they spent their time trying to reassure their clientele and advise that surgery was not appropriate. Like me they then bemoaned the fact that so many patients would go back to their GPs and get a referral to another less obstructive surgeon and they would then never see a referral from that GP again.

At this point I think it is clear where this has been going especially as there is much financial reward in scanning and intervening but exceedingly little in talking, education and reassuring (and then many don’t listen anyway).

But things do change direction when crisis points are reached. The numbers of VOMITs (Victims of Modern Imaging technology*) are increasing alarmingly and if you connect the dots with the pain neuroscience and placebo / nocebo stuff that I explain on this site (hopefully adequately) then you really can see the image of the perfect storm building to similar proportions as the problems with the ‘super bugs’..

I suspect we will be seeing similar billboards at some stage in the future regarding unnecessary scans.

*VOMIT (victims of modern imaging technology) – an acronym for our times. Richard Hayward, consultant neurosurgeon. BMJ 2003;326:1273:

“…The history of imaging since the discovery of x rays has been one of an exponential rise in the volume and accuracy of information, acquired against a background of firstly increasing and then reducing invasiveness—and rising costs … It is small wonder that the flood of information from these investigations and our knowledge of how to deal with it may be several years out of step … So where does this leave us doctors? We adapt to a world in which we must accept VOMIT as a reasonable price for our technological advances. But it’s also a world in which that well tried and tested concept, the doctor patient relationship, exists to help us translate the anxiety provoking generality into, we hope, the reassuringly individual.”

** MRI Poor Predictor for Return to Sports After Hamstring Injury. Medscape. Sep 03, 2015

 PS: First ever blog over and out. That feels good. Amazing what can be done lying in my hammock on a perfect Melbourne day with a laptop. What a great context I am fortunate to enjoy!

27/08/16 UPDATE (to reinforce the point of this blog):

I came across this publication which seemed quite relevant:

“Antibiotic prescribing and patient satisfaction in primary care in England: cross-sectional analysis of national patient survey data and prescribing data”

Check out the sad conclusion which applies oh, so well to scanning in pain:

Conclusion Patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.”

QED.