Low impact care for back pain

| June 4, 2024

Chronic pain has a devastating impact on sufferers, with women harbouring most of the burden.

The troubling paradox for women is this: while they suffer more chronic pain than men — they often find their reports of pain not taken seriously.

To add insult to injury, they are also often on the receiving end of sub-optimal assessment and treatment.

Women receive less and less effective pain relief, are prescribed more antidepressants, get more mental health referrals and are perceived as emotional, complaining, not wanting to get better, and fabricating the pain.

This makes women with chronic pain a particularly vulnerable group. Given these worrying trends in women’s care, it’s important women be made aware of safe and effective treatments available for their pain.

The march of medical marketing

Women’s health advocates point out that it’s important women be able to access treatment for their pain, and that it be taken seriously.

But there are increasing concerns this agenda is being hijacked by vested interests — namely specialists and companies which craft female health narratives to promote treatments not backed by evidence.

When it comes to pain management, spinal fusions and spinal stimulation devices are two pertinent examples, as a recent ABC Four Corners episode in Australia examined.

Spinal cord stimulators are surgically implanted devices that deliver electric impulses to the spinal cord. Despite aggressive marketing regarding their effectiveness, a high-quality review of all the scientific trials on these devices has found that spinal cord stimulators probably do not “have sustained clinical benefits that would outweigh the costs and risks of this surgical intervention”.

An analysis reported to Australia’s Therapeutic Goods Administration provides sobering evidence of the risks associated with these devices.

Of 520 adverse events associated with spinal stimulators reported between 2012 and 2019, 79 percent were considered “severe” and 13 percent were “life-threatening”. Compounding matters, these devices are also pricey: With hospital costs factored in, the total cost for a single procedure averages more than $58,000.

Spinal fusion is a surgery that permanently fuses two or more vertebrae together to stop them moving on each other.

A review of the literature found that fusions are not more effective than non-surgical treatments (such as exercise) and serious harms — which can include nerve injury, heart failure, infections and blood clots — occur in one in six patients. As well as being risky, the procedure is also expensive. In Australia, depending on one’s health insurance status, one surgery costs more than $41,000.

A new way to understand chronic pain

For decades, pain was understood to be caused by biological factors and disease pathology only. Most treatments were based on this assumption.

In recent years, many guidelines for various chronic pain conditions have shifted to focus on non-drug and non-surgical treatments.

This is a move away from harmful over-medicalisation — and is better aligned with the latest, evidence-backed view, which understands chronic pain as a personal biopsychosocial experience, which recognises that pain emerges from a dynamic interplay between biological, psychological, and social factors.

What works best

Addressing these factors in an individualised way is now considered best practice for chronic pain.

While in the past, a woman with chronic back pain may have been referred by her GP for imaging and drugs or referred to an orthopaedic surgeon, a more appropriate pathway for many types of pain may now involve a GP and physiotherapist working with the patient in an individual way to apply biopsychosocial techniques for pain management.

Depending on needs, some patients may benefit from referral to a dietician, psychologist, or occupational therapists.

Advice and information to improve a patient’s understanding of their pain or appropriate management is the most important and effective treatment. This includes how to stay physically active, managing setbacks, healthy lifestyle, and how to self-manage and cope with pain.

Unfortunately, many people miss out on education. Sufferers should ask their health professionals for simple explanations as there is strong evidence people with chronic pain want to be heard and validated, and working with a health professional who is a good communicator is important for patient outcomes.

Exercise and physical activity are another vital part of chronic pain management. We now know that regular exercise not only helps keep the body fit and healthy, but actually reduces pain and discomfort. It also relaxes muscle tension, helps mood and strengthens the immune system once started gradually.

When you are in pain, starting exercise can feel hard. Keep in mind that under-used muscles feel more pain than healthy muscles — so if you’re feeling sore after exercise, this does not indicate harm or damage to the body.

All types of exercise are good- so pick one you enjoy, can afford and which is convenient.

Chronic pain sufferers may also want to consider Cognitive Functional Therapy (CFT) , a new treatment developed for lower back pain, which can be adapted for other musculoskeletal pain conditions — as long as serious causes of the pain (for example, cancer or broken bones) are excluded. CFT is offered by some specially trained physiotherapists and other clinicians.

In this therapy, the clinician works with the patient to identify and address their individual barriers to recovery, coaching them to self-manage their condition and reach their goals.

It takes in body relaxation, awareness and control techniques before moving to lifestyle coaching for healthy sleep habits; stress management strategies; social engagement and work.

The effectiveness of this treatment is backed by research, with 11 clinical trials having already demonstrated CFT efficacy.

The largest clinical trial, published in The Lancet, included 492 people with chronic lower back pain. It found large and sustained improvements in function and reductions in pain levels for people who underwent CFT, compared with those receiving usual care.

People who underwent CFT were also more confident, less fearful and had a more positive mindset about their back pain.

Importantly they liked it, with 80 percent of participants satisfied or highly satisfied with the treatment, compared to 19 percent in the usual care group. The treatment was as safe as usual care and was also cost-effective. It saved more than AUD$5,000 per person over a year, largely due to increased participation at work.

Originally published under Creative Commons by 360info™.


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