Pain Management: Why do We Ignore What Works?

Chronic pain has become a ubiquitous health problem and demand for ways to prevent and treat it are widespread. Unfortunately, both patients and healthcare professionals often seek shortcuts to achieve pain relief. The reality is that for most people with chronic pain the solutions to effective pain management lie largely in what they can do for themselves rather than in what can be done to them. Two new papers highlight this.

The first is a review and meta-analysis of studies on methods to help prevent initial episodes and recurrence of low back pain (LBP).¹ Despite the fact that this is one of most common health problems for which patients seek physician care, the authors were able to identify only 23 published studies that met their inclusion criteria.

The analysis found the most effective method for preventing LBP was a combination of exercise and education which reduced the risk for LBP by 45% and also reduced by 75% the risk for LBP-related sick leave. These results reflect a mixture of studies that examined short-term and longer-term follow-up. While exercise alone provided some improvement in these outcome measures, education by itself did not.   

A combination of exercise and education reduced risk for LBP by 45% and risk for related sick leave by 75%.

The type of exercises employed varied from study to study and included stretching, and strengthening of abdominal and back muscles. The content of the education programs also varied and included review of ergonomics, training on lifting, and information on the anatomy of the back. The authors were unable to determine whether any specific exercise or education program was more effective than others.

In contrast, there was little evidence that several other commonly used methods for preventing LBP, including orthotic insoles and back belts, provided any benefit.

The benefits of exercise diminished at one-year follow-up, a result, the authors theorized, of subjects failing to continue the regimen. Subjects who were involved with both exercise and education did better at this point than those who received only the exercise program indicating that education may have been related to the continuation of exercise. 

The second paper examined the effects of weight reduction on the symptoms of osteoarthritis (OA) of the knee.² The patients, all of whom were considered possible candidates for knee replacement, were enrolled in an 18-week weight loss program that combined diet and exercise. The mean ages, height, and weight of the subjects were 64 years, 5'5", and 209 pounds, respectively.

It was found that at least a 7.7% reduction in weight was required to achieve a minimal clinically important improvement in function as measured by the Knee Injury and Osteoarthritis Outcome Score (includes subscales for pain, activities of daily living, quality of life). Those who achieved more than 10% weight reduction had the greatest improvement in all measures.

An editorial accompanying the LBP study notes that "If a medication or injection reduced LBP recurrence by such an amount [as was reported in the study], we would be reading the marketing materials in our journals and viewing them on television. However, formal instruction after an episode of LBP is uncommonly prescribed by physicians. This pattern is, unfortunately, similar to other musculoskeletal problems in which effective but lower-technology and often lower-reimbursed activities are underused.” ³

"If a medication or injection reduced LPB recurrence by [the amount reported in the study]," reads an editorial, "we would be reading the marketing materials in our journals and viewing them on television."

This statement would apply equally to the knee OA study: ie, how many physicians make a concerted effort to have obese patients with osteoarthritis of the knee lose weight before referring them for evaluation for joint replacement.

Results of a third study, which attempted to change physician behavior around ordering what it describes as “low-value diagnostic tests,” including MRIs for back pain,⁴ also are disappointing.

In the study, instructors portrayed patients who were seen by residents in internal medicine or family medicine. “Patients” requested specific imaging studies for LBP and for headache pain.   The subsequent rates of ordering tests by residents who received feedback from instructors was compared to that of those who did not receive feedback (ie, on appopriate use of imaging). No differences were noted in the behavior of the two groups.

The overall picture created by results of these studies is not a very encouraging one. Effective treatments and preventive measures for common forms of chronic pain, which may also improve overall health and are free of significant associated adverse events, often are overlooked while the use of diagnostic tests of limited if any value continues largely unabated.

Clearly when it comes to addressing chronic pain, we are often ignoring what works best.

References:

1. Steffens D, Maher CG, Pereira LSM, et al. Prevention of low back pain: a systematic review and meta-analysis.JAMA Intern Med. 2016;176:199-208.

2. Atukorala I, Markovey J, Lawler L, et al. Is there a dose response relationship between weight loss and symptom improvement in persons with knee osteoarthritis?Arthritis Care Res. 2016:DOI:10.002/acr.22805.

3. Carey TS, Freburger JK. Exercise and the prevention of low back pain: ready for implementation. JAMA Intern Med. 2016;176:308-209.

4. Fenton JJ, Kravitz RL, Jerant A, et al.Promoting patient-centered counseling to reduce use of low-value diagnostic tests: a randomized clinical trial.JAMA Intern Med. 2016:176:191-197.