To answers your questions on integrative pain management, review the monthly article written by David C. Leopold, MD, Director of Integrative Medical Education and Robert Alan Bonakdar, MD, FAAFP, Director of Pain Management of Scripps Center for Integrative Medicine in La Jolla, CA.
by David Leopold, MD and Robert A. Bonakdar, MD, FAAFP
We begin the series with an exploration of Integrative Medical approaches to low back pain (LBP). We will discuss important issues related to diagnosis and treatment options, and individualizing your low back pain treatment.
Because of the inherent biopsychosocial nature of Integrative Medicine, and the multifactoral etiology, including the significant biopsychosocial overlap of LBP, the Integrative Medicine Practitioner is ideally positioned to effectively diagnose and manage the patient with low back pain.
Low back pain (LBP) is a major chief complaint to the Primary Care Physician and the Integrative Medicine Practitioner, and is the fifth most common reason for all physician visits in the United States1, 2
. In fact approximately 25% of United States adults had LBP lasting at least 1 full day within the past 3 months 2
, and 7.6% reported at least 1 episode of severe acute low back pain within a 1-year period 3
. Many patients with acute low back pain will recover with minimal intervention, and do not seek medical care 3
. Based on Eisenberg’s previous data 4
, it is reasonable to extrapolate that a significant percentage of these patients either self treat or visit “Complementary & Alternative Medicine” practitioners. In fact, LBP is the most common reason for a visit to an Integrative Medicine Practitioner, at 16.8% of all Integrative Medicine visits 5
. Those who do employ medical care usually improve in parameters of pain, disability, and return to work within first month6
. However, 1 year after an acute episode, 20% of patients report significant limitations to activity, and up to one third report at least moderate intensity persistent back pain 7
LBP is costly in direct and indirect costs as well. In 1998, approximately $26.3 billion in direct health care costs in the U.S were attributable to low back pain8
. LBP is also a leading cause of disability, accounting for 16.5% of disability9
. Compensation for a back injury is applied to approximately 2% of the U.S. work force each year10
. A very small fraction (5%) of all disabled persons with back pain account for 75% of the total costs associated with low back pain11
Patients seeking an Integrative Medical approach for their LBP are often frustrated and in significant pain. This is echoed in the patient’s perspective of what makes a useful physician visit for their pain. Patients emphasized the importance of an explanation what was being done and what was being identified. Patients stated they wanted to receive understandable information on the cause, appropriate reassurance, a discussion of psychosocial issues, and a discussion of options that fit the problem & patient. The most important factor identified by patients: the specialist took the patient seriously 12
. The role of the Integrative Medicine Practitioner can thus be a difficult balance between compassion and understanding, enabling and providing false hope.
There are many reasons patients visit an Integrative Medicine Practitioners for LBP. The most commonly cited are a dissatisfaction with conventional care, higher intensity and duration of pain, a greater degree of self-care, encouragement of an “active coping behavior”, insurance coverage and income, addressing the sequelae of pain, and concern about the safety of conventional options. Ethnicity, greater physical activity & higher educational levels also predict CAM use 13,14.
In addition, based on our clinical experience the Integrative practitioner is likely to also see a subset of LBP refractory to conventional care, failed back surgery, or back pain without specific etiology.
In terms of diagnosis and treatment, perhaps no medical entity defies categorization as much as low back pain. In fact, the actual etiology differs depending upon individual practitioners & perceptions, with various practitioners citing entities such as muscle strain, vertebral subluxation, facet joint syndrome, disc issues, spinal arthritis, psychosomatic, and other causes as primary diagnoses. Not surprisingly then, diverse practitioners also have different perceptions on both effective therapeutic options and comfort levels treating this issue15
Indeed, there has been little consensus, within or across specialties, regarding appropriate clinical evaluation16
and management 17
of low back pain. Multiple studies show wide variations in the use of various diagnostic tests, and extent of diagnostics, and the treatments themselves18,19
. Despite these large variations in care, patients generally experience grossly similar outcomes, however care can have substantial cost differences among and even within specialties20,21.
Recently the American Pain Society (APS) and American College of Physicians (ACP) assembled a multidisciplinary panel and developed new, evidence-based clinical practice guidelines for low back pain published in the October 2007 Annals of Internal Medicine. The recommendations recognize conservative “traditional” treatments utilizing pharmacologic and non-pharmacologic therapies, yet there is now also recognition of therapeutic options proven effective in evidence-based trials. These include exercise therapy, spinal manipulation, acupuncture, yoga, intensive interdisciplinary rehabilitation, cognitive-behavioral therapy, and progressive relaxation.
Dr. Roger Chou the lead physician of the study noted “An important emphasis of the ACP-APS guidelines is that there are a number of effective noninvasive treatment options currently available for low back pain, albeit not the ‘miracle cures’ patients or physicians may hope for”. The panel noted that physicians should consider noninvasive, non-pharmacologic therapies described in the previous paragraph 22
It goes without saying that the conventional approach to LBP remains the standard of care and is therefore the place to begin. A standard work up, history and physical exam and diagnostics if appropriate are warranted. In the absence of serious pathology, the problem generator usually emerges as some combination of disc or joint pathology, myofascial dysfunctioning, neuropathic dysfunction, psychological dysfunction, nutritional irregularities (including obesity) or a combination of the above.
An emerging phenomenon in the cause & treatment of CLBP is that of central sensitization: the constant influx of pain messages from the peripheral nervous system to the CNS, setting up “pain loops” or constant pain messages. This may occur even in the absence of continued pathology at the original site, resulting in an alteration of neurophysiological pathways.
We have become comfortable with this type of thinking in the setting of RSD, phantom limb pain or fibromyalgia (FM), but in fact many CLBP patients now appear to have a localized hypersensitivity syndrome which can be detected on physical exam (i.e. allodynia and hyperalgesia).
Using fMRI, Giesecke et al. showed evidence of altered central pain processing in idiopathic chronic low back pain and elucidated many similarities with fibromyalgia and idiopathic CLBP. At equivalent levels of pressure, CLBP and FM patients experienced significantly more pain and also showed more extensive, common patterns of neuronal activation in the cortical areas associated with pain. Neuronal activations were also similar among the 3 groups when stimuli to elicit equally painful responses were applied. The stimuli also required significantly lower pressures in both patient groups as compared with the control group 23
In another study of chronic low back pain patients, generalized deep-tissue hyperalgesia was demonstrated in patients with radiating pain and MRI confirmed intervertebral disc herniation 24
In fact, it now seems apparent that chronic back pain alters the human brain chemistry. Grachev measured multiple neurochemical parameters (N-acetyl aspartate, creatine, choline, glutamate, glutamine, gamma-aminobutyric acid, inositol, glucose and lactate ) and found reductions of N-acetyl aspartate and glucose in the dorsolateral prefrontal cortex of patients with CLBP. In chronic back pain, the interrelationship between these neurochemicals within and across brain regions was abnormal, and there was a specific relationship between regional chemicals and perceptual measures of pain and anxiety 25
Writing in the Neuroscience Letter, Flor stated: “Chronic pain is accompanied by cortical reorganization and may serve an important function in the persistence of the pain experience.” 26
This was later followed with research showing that the adult brain is capable of substantial plastic change in such areas as the primary somatosensory cortex which was previously believed to be modifiable only during early life. The authors postulated that central alterations may be viewed as “pain memories” 27
. Dovetailing on this idea is the concept that cortical plasticity related to chronic pain can thus be modified by behavioral interventions that provide feedback to the brain areas that were altered by somatosensory pain memories 28
de Charms and his team utilized real time fMRI to
show that individuals can gain voluntary control over activation in a specific brain region given appropriate training. They further showed that voluntary control over activation in the rostral anterior cingulate cortex (rACC) leads to control over pain perception, and that these effects were powerful enough to impact severe, chronic clinical pain 29
Another reason Integrative Medical approaches can be so beneficial is that they are multifactoral. This becomes increasingly important once we realize that LBP involves far more than just the low back itself: It appears that efficacy can be achieved in significant amounts without ever addressing the low back region proper.
A study of breath therapy for patients with chronic low-back pain showed changes in standard low back pain measures of pain and disability that were comparable to those resulting from high-quality, extended physical therapy 30
And finally, a 2006 study demonstrated that after previous surgery for disc herniation there was an equal rate of success in the use of cognitive and exercise approaches compared with spinal fusion. Cognitive approaches included education and advice about LBP, the importance of movement and activity, and exercise consisted of aerobic or outdoor activities, pool therapy, and individual exercises. Results were measured by pain intensity, use of daily drugs for pain, and general function and showed improvements of 50% for spinal fusion vs. 48% for cognitive intervention with exercise. The authors concluded: “For patients with chronic low back pain after previous surgery for disc herniation, lumbar fusion failed to show any benefit over cognitive intervention and exercises.” 31
As we go forward in this series we will discuss in further detail many of the treatment interventions we touched upon today. We will show how an individualized integrative medical approach to patient’s low back pain can have significant benefit, even in, and perhaps particularly in the context of the “failed back” or “etiology unclear” patient. We will discuss the appropriate use of, and potential pitfalls of Integrative Medical approaches to low back pain.
In addition, we will show how multiple other non-conventional treatment methods, ranging from natural anti-inflammatory supplements (e.g. NAISs), novel DMARDs (e.g. avocado-soy unsaponifiables, glucosamine) to bio-energetic modalities (e.g. percutaneous neuro-stimulation / low intensity laser therapy / Healing Touch) can be of benefit to the patient with chronic low back pain. We will also explore the pros and cons and evidence for emerging treatment modalities such as prolotherapy / regenerative injection therapy and trigger point therapies.
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