The other day I came across this New York Times article that initially made me angry. “The Secret Life of Pain” describes the author’s journey from debilitating, job ruining, chronic pain, to a life with more choices, less pain, and more mobility, by practicing mindfulness?! Deep breathing?! Not giving into the pain?!
I was indignant on behalf of many of my clients who suffer severe chronic pain. I have one client who doesn’t sleep more than two or three hours a night. Another who sometimes has to use crutches to get around. How could the author make such infuriating, non-medical claims?
However, I know the article is right.
Let me explain.
Several years back I edited an article written by several doctors and a chiropractor who had conducted research on the familiarity of family physicians with the chronic low back pain treatment guidelines. I learned a few worthwhile things from that paper. First, non-specific low back pain affects millions of people around the world; 10-12% even develop into chronic pain situations, similar to how the author in the New York Times article described it. However, no one truly understands the origin of this pain. Nor do they recommend routine MRIs, CTs, or opiate based medication to treat this condition.
The current protocol from the American College of Physicians reiterates this statement, “For treatment of chronic low back pain, clinicians should select therapies that have the fewest harms and lowest costs because there were no clear comparative advantages for most treatments compared with one another. Clinicians should avoid prescribing costly therapies; those with substantial potential harms, such as long-term opioids (which can be associated with addiction and accidental overdose); and pharmacologic therapies that were not shown to be effective, such as [tricyclic antidepressants] and [selective serotonin reuptake inhibitors].”
The Israel Medical Association released their version a few years back that supports this statement as well. They add that special orthotics, mattresses, or lumbar back belts have not been shown to be effective in reducing back pain and that those in pain should be encouraged to keep moving, engage in exercise, and not take off from work. Words that profoundly seem to echo the sentiments of the New York Times author.
So, what are these guidelines saying? That a healthy adult who sees a doctor for back pain that is waking them up at night and keeping them home from work should NOT be sent for an MRI, NOT prescribed OxyContin and NOT told to rest; according to all the guidelines, these patients should be instructed to move, breathe through the pain, exercise more, and not take heavy drugs. Pretty much as described in that New York Times article: mindfulness, deep breathing, not giving into the pain.
Interestingly enough, the article that I edited found that despite the relatively high level of guideline knowledge of LBP treatment, the majority of the Israeli physicians sampled were not implementing these internationally accepted guidelines.
Why not? Well, first maybe because, just like my first reaction, it does seem counter intuitive to tell someone to not change their physical behavior when they are in pain. After all, if you break your arm, I wouldn’t tell you to wave it in the air, would I?
Next, doctors are human. They have empathy for the person in front of them who wants someone to recognize their plight and do something about it. What doctor worth his/her salt won’t send you, at the very least, for an imaging test if you come in presenting with severe pain? Patients want to do something. And mindfulness, yoga breathing, and going to a chiropractor may not seem to them like they are “doing something”.
Finally, sometimes it’s not chronic pain. It’s something far worse. My brother in law went to the doctor complaining of severe leg pain. He was diagnosed with sciatica. Finally, they gave him an x-ray of his leg. Must be sciatica. Turns out they missed the tumor in the bone by inches.
Isn’t that our fear? The doctor’s fear? What if we miss something?
When is chronic pain different than, well, chronic pain?
Here are some guidelines for all of us if we go to the doctor with this problem:
- Know your problem: ask yourself, how long have I had this pain? Was there a trigger that I was aware of? Was it a sudden or slow onset? – write this down.
- Keep a pain diary: you would be surprised how much we can learn from patterns when we see them mapped out over a week or two. Our brain is so occupied that we won’t be able to see connections unless we draw out a bigger picture.
- Fibromyalgia is a recognized illness and it is not the same as lower chronic back pain and the treatment protocol is not the same. Make sure that your doctor is treating you for the right illness.
- If you feel that your doctor has taken a reasonable history and has diagnosed you with non-specific lower back pain, don’t be resentful when you are prescribed Advil, tai chi, and a name of a good chiropractor. This doctor is actually aware of the international consensus and practicing evidence based medicine.
- A doctor’s treatment plan is just that, a plan. Every plan needs to be implemented, then evaluated, and possibly revised. Agree on a time with your doctor that if, after x amount of weeks, there is no change, or if worse than sooner, you will return for a follow-up evaluation. I’m always surprised when I sit with people and they tell me, “Well, the doctor gave me this medication for heartburn, but it’s not working.” “When did he prescribe it?” I ask. “Oh, I saw him about 5 months ago.” So my follow up question is, well, why didn’t you go back? Interesting excuses notwithstanding, make an appointment while you’re in the doctor’s office for a follow-up appointment in 6-12 weeks from now. Every plan needs follow up.
- We are often worried about worst case scenario. The problem is statistics are against us. Most times it is usually chronic back pain and not a cancerous lesion. So we need to do our due diligence, and follow up accordingly if the situation does not improve.
- This next concept is perhaps for practitioners and caregivers as well. My brother in law went to the doctor with pain in his leg. In my opinion, the doctor should have seen the person in front of him, a 55 year old business man who was taking serious pain killers who, when asked how his pain was on a scale of 1 to 10, answered 7 (10 being eaten alive by wasps. Obviously his pain scale was different than mine). The doctor should have known that the person in front of him would only come in if the pain were excruciating and to respond differently than he would have had a different patient come in with the same problem.
- This is why having a relationship with a doctor is so important. So they can see changes in your behavior, attitude, etc… and respond accordingly. Today, doctors are inundated with patients, overwhelmed by paperwork and seriously understaffed. We can help by presenting our histories clearly, having thought about our pain beforehand to present a succinct story, and following up with our doctor in a timely fashion. Those things are our responsibility.