Living in the Grey Zone: Back Pain

Thanks to all who participated and attended the Grey Zone: Acute Back Pain lecture last Tuesday.  I learned a lot, hope that you did as well.  As is often the case with grey zone lectures, we spend so much time talking with the panel that we miss some of the didactics at the end.  Here are some highlights that I wanted to be sure to cover.

99% of patients will acute back pain will get better, often without you doing much at all.  Gentle activity, NSAIDs, and time will take care of most.  If it goes on for two-week or so, add some formal PT. The activity is good, but PT will also use massage, heat, TENS and US to help get the muscles to relax.

Red flags aren’t all they are made out to be, but are definitely a clue to slow down your thinking about a patient with back pain.  You may not need to do more just because a patient has one red flag-  80% of patients will have at least one.

Yellow Lights mean “slow down and prepare to stop” according to my 5-year-old, and that is just what these should signs and symptoms should make you do.

  • Age >70
  • History of cancer, not active malignancy
  • IV drug use
  • Osteoporosis, use of steroids
  • Immunosuppression

On the other hand, the red lights should make you stop and seriously consider more imaging, consultation, or other workup. You may still be justified in delaying imaging if there are one of these present, but you need to be extra sure that it is the right thing to do.

  • Known metastatic cancer
  • Trauma
  • Recent spinal surgery
  • Bowel/Bladder incontinence
  • Fever (without another reason)
  • Weight loss (without another reason)
  • Saddle anesthesia, decreased rectal tone
  • Progressive motor or sensory loss

If you do need to do more workup, let your differential diagnosis be your guide as to what needs to happen.  Here are some suggestions:

  • Vertebral Fracture: either from osteoporosis or trauma.  Plain films are quite helpful, CT is important for traumatic fractures- will give a better idea of the extent of the fracture and the mechanism.
  • Metastatic disease: Plain films are a place to start.  MRI would be quick to follow if there are neurologic findings.  Bone scan may be useful in a high risk patient with a less clear picture.
  • Cauda Equina Syndrome: Think this if there is saddle anesthesia, bowel/bladder incontinence. MRI if you are concerned, with quick referral to NSGY.
  • Spinal Stenosis: Pseudoclaudication is the classic sx here: predictable pain with standing or walking, better with rest.  Vascular claudication gets better quickly with rest, pseudoclaudication takes 20-30 minutes or more. Plain films may show misalignment, but the MRI is going to clinch the diagnosis.
  • Epidural abcess: Unexplained fever and weight loss in a high risk patient: IV drugs, recent spinal surgery, recently septic, decubital ulcers all are all risks. MRI is the imaging test.

Here’s a great patient centered video about low back pain to bring these points home to your patients.

Life is Pain, Highness

Noon conference this week was about safe opiate prescribing. I hope that some of you were there and enjoyed it.  As I was making the talk, I felt that I also wanted to learn/teach more about chronic pain and how to treat it.

Most of this information comes from a great TMS (no really) course on Complex Chronic Pain.  If you are interested in the topic, I recommend the course. TMS is here, and you can find the course by searching for V07 Complex Chronic Pain Course. Of course you have to be a VA employee to access TMS.

Do you have patients in your clinic that carry a diagnosis of “Chronic Pain.” Not chronic back pain, or osteoarthritis, or fibromyalgia, but just “chronic pain.” It has been a pet peeve of mine, to label the pain but not the etiology, but turns out that it is a real thing, and our traditional biomedical model just doesn’t do a great job at addressing the issue. We start out with the right things: history and physical, careful testing, conservative treatment. When that doesn’t work, we might refer to a specialist, or PT, or send the patient for injections. Slowly we tread into unproven, non-evidence based therapies, which often don’t work either. Or, the patient feels a little better; often because they felt that they were heard and they believe in the treatment plan, not because the therapy worked.  We keep doing the same things and expecting a different result. the patient feels that their life is on hold while their doctor gets their pain under control. Eventually, the patient gets frustrated with us, we get frustrated with the patient, and the relationship becomes strained.  Often, the patient finds a new doctor and the cycle starts over again.  We are all frustrated and unsatisfied, and we resolve not to do that again.  But we do, because the tools we have are insufficient for the problem

.Components of Chronic Pain

A new way to think about this is from a biopsychosocial model. The root cause of the pain is as much psychosocial and emotional as it is biological, and emotional and social stressors make it worse, just as lifting a refrigerator would. In this model, the doctor has to give up some control, it is really up to the patient to get better. We become the coach, the therapist, rather than the omniscient expert with the prescription pad.  The goal shifts from relieving pain to restoring function and improving health.  Patients move away from a focus on ending pain and minimizing symptoms to “expecting pain” and living their life in spite of that.  The office visit is less about pain control and more about setting and achieving functional goals.  Your job is to teach patients that you hear their frustration and believe that they have pain, but there isn’t a medical solution to this problem, and the two of you are going to work together to help them move on with their life.

there are no magic pills

Chronic pain is aggravated by a variety of things. If you can identify these in your patient, you may be able to help them move forward in recovery. The first is deconditioning: think like an athlete in spring training, they don’t expect to come in at mid-season form. Second is poor coping skills and ineffective stress managment techniques. We should teach that pain is not necessarily leading to more damage, but represents a bump in the road that they will move past.  Pain is inevitable, but misery is optional. Finally, outright mood disorders can aggravate pain. It is reasonable to aggresively seek out and treat these, but in such a way so that the patient doesn’t come away feeling that you don’t believe their pain.

How to help the patient set goals. These need to come from the patient, not you.  Ask about what they want to do, but can’t now.  Listen carefully and pick up on anything that the patient identifies, then try and troubleshoot the barriers.  If they want to exercise, but always have increasing pain, then try and reduce the intensity back to a level that they can acheive. Set goals that seem too easy, too simple, so that you can build on successes- first you have to have successes.  If the patient is not even getting dressed every day, make that a first step. Later they can work toward the gym membership, but if you try and do it all at once, they will end up hurting and less likely to try again.

Goals need to be acheivable, almost easy for the patient. Then build on success.

If you have access, pain psychology or mental health providers can help with cognitive behavioral therapy around coping mechanisms, goal setting, and stress managment techniques.  You can also teach your patient some simple stress managment. Deep breathing and meditation is a simple concept to understand and provides a coping strategy for the patient to deal with pain.  There is an app “Breathe 2 Relax” that teaches deep breathing and website calm.com that does guided imagery relaxation.

6b71f548f5feffd1eff285ddb315e09b

The trick for all of this is getting patients to buy in. They are doing all of the work and the motivation has to come from within. So long as you really listen to their pain story, and have done an adequate evaluation, you don’t necessarily change the treatment plan because of resistance. However, don’t become confrontational, don’t fight.  Pushing hard for patient self managment strategies will often backfire.  Use your best Motivational Interviewing jujitsu to roll with resistance and put the onus to change back onthe patient. They can certainly stay the same, but you might point out that isn’t getting them anywhere.

Chronic Pancreatitis

Guest Poster:  Chronic pancreatitis  by Dr. Josh Stripling

 Definition: Irreversible destruction of the pancreatic parenchyma causing varying degrees of endocrine and exocrine dysfunction

  •  most patients typically present with persistent abdominal pain and steatorrhea
  • exocrine dysfunction – chronic diarrhea and weight loss
  • approx 20% present with maldigestion without pain

Causes:

  • The most common cause of chronic pancreatitis is alcohol use (usually more than 10y and more than 50g/day)
  • TIGAR-O (Toxic-metabolic, Idiopathic, Genetic, Autoimmune, Recurrent and severe acute pancreatitis, Obstructive)
  • tobacco also increase the risk of developing chronic pancreatitis

Diagnosis:  there are two specific entities: large- duct and small-duct (minimal change)

  • no consensus on gold standard for diagnosis: difficult testing and not always available
  • typical diagnosis is clinical based on symptoms and imaging
  • available testing includes: Secretin and CCK stimulation tests, fecal elastase, serum tripsinogen, stool sudan stain
  • most patients should undergo MRCP (not ERCP) or EUS to evaluate pancreatic ducts
  • patients can progress to development of pancreatic cancer

Plain film or CT can highlight pancreatic calcification to support the diagnosis

Management

  • avoidance of cause: EtOH cessation, pancreatic duct stenting, etc.
  • enteric coated pancreatic enzyme supplementation (40,000 units of lipase recommended) plus acid suppressant
  • fat-soluble vitamin replacement
  • monitor for endocrine dysfunction
  • pain management is difficult and theoretical improvement in pain with enzyme supplementation may occur
  • total pancreatectomy with islet cell transplantation is becoming more frequent

Resources: MKSAP 16, Harrison’s, “Chronic Pancreatitis” AFP 2007

Images: Medscape, http://www.meddean.luc.edu, healthcentral.com, drug3K.com