Why Pain Management?
 
When should you investigate back pain?
 

It is estimated that 50% of working adults suffer from back pain and 15-20% seek treatment. This is an enormous strain on medical facilities, the workplace, the individual, and society. Acute back pain is defined as activity intolerance as a result of back or back-related leg pain of < three months' duration. About 90% of these individuals will recover spontaneously, but the remainder will need special management. Chronic back pain is a syndrome that has physical, psychological, and social components. This is known as the biopsychosocial model.

There are many physical causes of back pain from trauma to degeneration of the different anatomical structures of the back. Initial management of these patients is to determine the etiology of the pain and create a custom treatment plan. If the condition is severe, such as with a fracture, nerve involvement, cancer, tumor progression, infection, inflammation, or recent onset of neurological deficit, advanced therapy may be needed. If these severe conditions are not present, then early return to work should be facilitated.

If the back pain is simple, then treating with simple analgesics is usually adequate. Medication side effects should be monitored. Educating the patient on how to walk, stand, lift, and general back care is extremely important. Encouragement to return to work and normal activities promotes healing. Walking and water exercises are very helpful.

If there is nerve root compression, treatment will depend on the severity. Less severe cases may respond to conservative management. More severe pain may require physical therapy (PT) to avoid debilitation. PT should focus on mobilization, pacing of activities, and setting realistic goals for the patient. Postures and movements that aggravate the pain should be avoided and this may require some lifestyle changes.

Gradual increase in activity is important. Conditioning exercises for the back may be stressful initially and should be avoided in the first few weeks. Patients with sciatica will have longer recovery times and may need more advice for back care than patients with less specific symptoms.

Radiographic evaluation may be helpful if one remembers that anyone > 30 y/o will have "abnormal" findings. It does not always benefit the patient to ascribe these changes as an etiology of the pain. Routine blood work may show some medical condition as the cause of the pain. If physical exam suggests tissue damage or neural impairment then further radiological testing is indicated.

Many patients with a disc problem will return to normal activity within a month. There is nothing to indicate that waiting for this period of time will make the condition worse. Most of these patients improve whether or not they have surgery. Surgery may speed the recovery but only benefits about 40% of patients. Referral to a specialist should be delayed until three months of conservative therapy have failed unless severe symptoms occur. If a patient has adverse neural tension of < six months' duration, epidural steroids may help. If just one root is involved, a single injection to that root may be effective.

Lumbar facet and sacroiliac joint injections are indicated when stressing these joints provokes pain. Post procedure evaluation is important to differentiate between immediate pain relief (which suggests pain arising from the joint, responsive to radiofrequency denervation) and pain relief of gradual onset peaking at 48 hrs (which suggests inflammation of the surrounding tissues, and is more likely to benefit from further steroid injections).

Treatment with botulinum toxin may be indicated for patients with abnormal rigidity of the paraspinal muscles that does not respond to medication management. Muscle relaxation peaks at six weeks and lasts for up to three months. Patients should be taught to maintain good posture, movement, and activity management during this time.

Additionally, the multifaceted psychological needs of the patient must be treated. Behavioral dysfunction can be challenged and relaxation techniques, biofeedback, and returning the "locus of control" to the patient are all aims of intensive pain management programs. These programs are combined with physical therapy, injections and concurrent drug therapy.