Treating Pain Before It Becomes Chronic

Mandeep Othee, M.D.Board Certified, Physical Medicine and Rehabilitation and Board Certified, Pain Medicine

What is Acute pain? Associated with specific cause such as fracture, disc bulge/herniation, recent

surgery/medical procedure

Some degrees of pain are normal, like discomfort during the healing process just after surgery or a healing bone fracture

Usually acute pain resolves in days and up to several weeks

What is chronic pain? Does not heal

May be present for months and even years

Increases burden on society with longer hospital stays, lost worker productivity, lost income, loss of health insurance coverage

Chronic pain statistics Over 100 million Americans suffer with chronic pain which is more than the

number of Americans with diabetes, coronary arterial disease, stroke and cancer combined!

Pain costs America at least $560-$635 billion annually which is equal to $2000 for everyone living in America, which includes $297-$336 billion due to lost worker productivity.

Chronic pain statistics Back pain is the leading cause of disability in Americans under age 45.

More than 26 million Americans between ages of 20 and 64 experience frequent low back pain

80% of adults experience low back pain at some point in their lifetimes.

Focus on Low back pain Second most common reason to see primary care physician after

flu/”common cold”

Second most common pain condition prompting lost worker production time after headaches

Workers lost 5.2 hours/week of productive time

Low back painCommon Thinking

40-50% of patients with low back pain will improve within one week

The Full Story

62% of patients likely to have one or more relapses during a one-year follow-up

Low back painCommon Thinking

85-90% of injured workers with low back pain will improve in 6 to 12 weeks

The Full Story

Low back pain is the #1 disability in patients under 45

After two years, there is little to no chance of returning to previous job

Low back painCommon Thinking

90% of patients with low back pain improve without any medical care

The Full Story

Longer pain for patients who wait 6-10 weeks

80% have pain at six months and one year

12% disability at one year

Low back painThe Financial Bottom Line

LBP accounts for $25 billion in medical costs annually

LBP contributes to another $50 billion in non-medical costs each year

Low back painLBP Negatively Impacts:

Worker’s Quality of life

Increased Employer costsIncreased US healthcare system costs

Low back PainDifficulties in Treating LBP

Difficult to diagnose source

Requires “whole care” approach

Preventive program needed to minimize recurrence

The Physical Medicine and Rehab SpecialistWorks to restore or maximize function by limiting use of opiate narcotic pain medications and avoiding surgery

Integrates elements of:

orthopedic/musculoskeletal care ( branch of medicine emphasizing the prevention, diagnosis, and treatment of disorders – particularly related to the nerves, muscles, and bones – that may produce temporary or permanent impairment)

neurologic care

rheumatologic care

Treating the LBP Patient

Appropriate evaluation and diagnosis starts with history and physical examination

physical exam: neurologic and functional

psychosocial profile including functional work profile analysis

Diagnostic tests Initial X-ray Lumbar spine rule out fracture MRI Lumbar spine if no pain relief after 6 weeks of conservative care 40-90% of patients will have complete relief of pain using these

measures

Conservative care for LBP

Anti-inflammatory medications and ice as needed

No more than 1-2 days of bed rest

Physical therapy/chiropractic treatments

Proper lifting techniques: avoid excessive bending forward with twisting motion

Conservative care for LBP Maintaining good posture

Ergonomic support with office based tasks

Weight and diet management

Exercise 30 minutes a day and quit smoking if applicable

Avoiding Opiate Narcotic pain medications 80% of world’s narcotic pain medications are written in US

44 people die each day of from narcotic prescription drug overdoses

Interventional treatments for LBP Lumbar epidural injections

Lumbar nerve blocks followed by nerve ablation

SI joint injections

Avoid surgery if possible which has mixed results and which may lead to degenerative disk disease at levels above and below surgery

LBP Outcomes

Natural distinction between pain and function

Function may be restored even though some pain may remain

What to tell patients/injured workersThey are likely to improve and likely to return to work quickly, even if pain persists

Back pain is usually recurrent

May become chronic

Most patients with chronic LBP continue to work

Goals of Treatment Return to normal functional activity

Prevention of further injury

Optimal core abdominal strength, endurance and conditioning.

Staying active is KEY!

Effects of Immobilization

Atrophy

Deconditioning

Impaired function

Important Reminders Symptom resolution is only an initial step

Goal is prevention of recurrent injuries

PM&R Specialist can:

Reduce pain

Increase function

Lessen risk of recurrence

Maximize quality of life and

KEY is early intervention to prevent pain from becoming chronic and to have the patient/worker return to work with full duty as soon as possible.

References Institute of Medicine from the Committee on Advancing Pain Research:

Relieving Pain In America: A Blueprint for Transforming Prevention, Care, Education and Research. The National Academies Press, 2011

www.CDC.gov

National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.

Results from the American Productivity Audit. www.ncbi.nlm.nih.gov/pubmed/14665809

References 2006 Voices of Chronic Pain Survey from the American Pain Foundation

www.aapmr.org