Musculoskeletal pain
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7363.534 (Published 07 September 2002) Cite this as: BMJ 2002;325:534All rapid responses
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Unfortunately, Main and Williams (ABC of Psychological Medicine-
Musculoskeletal Pain-BMJ September 7) really "missed the boat" on the
latest effective treatment for low back pain. Recent research has shown
low-level heat therapy to provide a multitude of therapeutic benefits far
better than oral analgesics for treating low back pain (1).
This new portable heat wrap technology is ideal for self-management
of low back pain and allows for discreet delivery of continuous low level
heat (CLHT) for several hours while allowing patients to perform all their
activities of daily living.
The authors' recommendation that "analgesic drugs be taken on a
regular rather than pain contingent basis" lacks consideration of patient
safety. Oral analgesics have a long history of serious complications
(gastrointestinal erosions, excessive bleeding, hypersensitivity)
associated with chronic use, overdosing, and drug-drug interactions.
Recent research has shown that there is a new way to conceptualize
pain -- by it's responsiveness to therapy. Heat Responsive Pain is
emerging as one of the "hot" new topics in studying pain and CLHT is
potentially an effective treatment for a wide variety of pain syndromes.
1. Nadler S, et. al. Continuous low-level heat wrap therapy
provides more efficacy than ibuprofen and acetaminophen for acute low back
pain. Spine 27:1012-1017, 2002.
Competing interests: No competing interests
I must congratulate the authors for an excellent review of the
importance of psychology on the impact of pain. I, on a day to day basis as
an orthopaedic surgeon, make decisions that are life and limb threatening
to my patients and so need to take these factors before subjecting
patients to surgery.
Evidence for this comes from well accepted papers in spinal and
arthroplasty surgery of the knee, in which the patieints who achieve the
best clinical results are those that are the most highly motivated and
those that have indicators for psychological & social problems have a
poorer outcome. This paper provides a template consider the impact of
psychological issues and should be considered along side clinical findings
and not in isolation.
To the colleagues that remain sceptical about the impact of psychology
can I draw yor attention to when you may have been doing DIY. All of the
sudden you see spots of blood on your work surface. It is not until you
examine your hand that you realise that you have cut yourself. The pain
from the cut only registers after seeing the cut. If there had been no
blood to raise your index of suspicion than you would not have seen the
cut and consequently not felt pain. Similarly the patient with
musculoskeletal, pain such as arthritis, manages to cope with the pain
until the point where surgical intervention is required.
Competing interests: No competing interests
When I have pain, my first preference is for a clinician who is a
"technician" - to prevent, cure or ameliorate it. Only then would I be
interested in a "guide" to cope with what is left.
This article appears to portray pain as a minor inconvenience blown
out of proportion by flawed individuals. This can be far from the truth.
It can be a major burden, perhaps from injury or disease, and can be our
body's way of preventing further injury by making movement unpleasant.
The article is basically saying "put up with it, don't inconvenience
anybody about it, not practitioners, not employers, not family or
friends".
This approach carves out more ill-health territory for psychologists
and psychiatrists without giving anything beneficial to patients.
If I, not a practitioner, can see the logical flaws in this article,
and so many like it in the BMJ and elsewhere, why did the peer-reviewers
and editorial team miss them? How many times will such articles be
published, and people challenge them, before the government, medical
bodies or the public demand more genuine "evidence-based" research?
Competing interests: No competing interests
Sir,
I refer to the article by Main and Williams in which we are
introduced to the "new understanding" of back pain.
Writing as one who once suffered from serious back problems, this
complicated appearing article is quite a puzzle.
That is unless the scheme involved is to expediently fit a human
misery to an a priori "model".
On the subject of the chronic aspects of back pain we learn that…
"The key psychological factors that favour chronicity are:
The belief that back pain is due to progressive pathology
The belief that back pain is harmful or severely disabling
The belief that avoidance of activity will help recovery………."
Phineas Quimby and Mrs.Mary Baker Eddy would have been delighted.
I may be wrong, but I rather think that most people, most of the time, actually use their reliably evolved senses to decide what
does or does not help. Amazingly, we are all equipped with brains and feed back systems with an integrity which developed
over aeons. It is part of our normal functioning to know something of how best to recover after injury, and how to spot rotten
advice. We are even cognizant of the fact that ignoring the protective mechanisms of pain or fatigue can lead to further tissue
damage.
Surely the key to chronicity is to be found in professional ignorance
and disinterest about causes, rather than the authors` apparent belief,
that all who suffer from low back pain, are of low intelligence.
D T Fraser.
Competing interests: No competing interests
Bio - Psycho -Social Evaluation
Regarding this and other titles in the ABC series I am convinced of
the value and merits of the process of reasoning along bio - psycho -
social lines .
Perhaps what needs to be separated out in many cases are the words
themselves 'pain' and 'musculoskeletal' . There is not not a direct
correlation between the two and this has guided practice and intervention.
We know that there is a poor correlation between 'logical' evidence ie
imaging and pain perception/disability.
The move away from a purely technical biomedical interpretaion of
many musculoskeletal pain problems is not a desire by Psychologists to
create a niche for themselves. One of the leading authors in this field
is Prof Waddell (Orthopaedic Surgeon) his book 'The Back Pain Revolution'
is recommended
Pain is one of the most difficult clinical problems due to the
obvious difficulty in separating the sensory/emotive and cognitive
dimensions of the pain experience.
Models of pain are necessary and not to serve the ends of psychologists or
the careers of neuroscientists but to guide clincal practice and service
delivery.
Eienstein in 1926 informed Heisenberg that it was nonsense to found a
theory on observable facts alone : 'In reality the very opposte happens. It is theory which decides what we can observe'
Regarding pain, theory not only determines what we observe in
physiology but it determines how we treat people in pain.
See the excellent article by Professor Melzack Pain: Past Present and
Future
http://www.alternatives.com/raven/cpain/melzack2.html
In many cases technical solutions for ameliorating pain 'work' for
very different reasons than originally thought . A 'logical' problem like
osteoarthric knee pain has been shown to be influenced by placebo
arthroscopy
Mosely JB et al Controlled Trial of Arthroscopic Surgery for
Osteoarthritis of the knee. The New England J of Medicine , Vol . 347:81-
88,July11,2002,No2 plus editorial ,pp132-133
I am a NHS Physiotherapist with an interest in pain physiology and
preventing treating chronic pain . The issues I face clinically are
largely undiagnosable pain . None of the articles mention the role of
somatosensory input/modualation which is provided by a whole host of
people/professions ---everything from acupuncture,massage,heat,
manipulation etc may have a role in modifying pain perception ....
Movement is very important and especially in chronic pain .
Professor Wall in his last book before his death last year 'Pain The
Science of Suffering' took a global look at the whole pain experience
which is recommended to patients and medical practitioners alike.
I agree that we are fully equipped to deal with pain based on our
well developed sensory systems of feedback evaluation and activity.
The trouble is the world we were designed for is very different from
the world we inhabit now and very few people exhibit instinctive behaviour
in any field of life ....
Lifestyles are ofen enforced periods of ischaeamic
activity(sitting/driving/modern work etc etc) with subtle low grades of
neurohormonal changes which many are ill equipped to deal with .This is
why current pain physiology is integrating stress biology into its
thinking?
As far as heat wraps are concerned I agree that the feeling of
continuous warmth and normal activity would be highly bennefical for
reducing the risk of chronic pain and one that any health practioner would
support .
The high afferent stimulus may block the perception of pain and movement
may increase blood supply . However any tool has to be employed with an
awareness of the issues raised by Main and Williams .
It seems logical to follow the screening or flagging system to offer
the best options for appropriate care ....In back pain this may range
from a simple leaflet , detailed neurological examination , somoatosensory
input with support and graded rehabilitation/stress management to
referrral to referal to an oncologist ......
We know that a high initial pain presentation may proceed to chronic
pain and so individual treatment is required.
The volume of people unnecessarily disabled by the biomedical model
in treating back pain is the reason there needs to be shift in thinking
which in turn should shift clinical practice .
The reason many people trust groups ouside the mainstream is that often
the care is more individual and attention is paid to the individual in
pain regardless of the ethos of the profession concerened....
I do feel that the current interest in neuroscience and pain
physiology is helping to bridge the dualistic divide in many professional
groups Physiotherapy being one example.
Ian Stevens, Dunblane, Scotland, UK
i.stevens@virgin.net
Competing interests: No competing interests