"Scans for Back Pain Ineffective"

Tara Parker-Pope published this article yesterday in the NYT: Scans for Back Pain Ineffective

She can say that again. Not only does the scanning or imaging process do nothing whatever for the "pain", it may result in misleading interpretations of the imaging; well-meaning people may consider or resort to treatments that reinforce the problem rather than help the pain experience to disappear.

Excerpts:

"Researchers from Oregon Health and Science University in Portland reviewed six clinical trials comprised of nearly 2,000 patients with lower back pain. They found that back pain patients who underwent scans didn’t get better any faster or have less pain, depression or anxiety than patients who weren’t scanned. More important, the data suggested that patients who get scanned for back pain may end up with more pain than those who are left alone, according to the report published this week in the medical journal Lancet."

"The problem, say researchers, is that back scans can turn up physical changes in the back that aren’t really causing any problem."

“You can find lots of stuff on X-rays and M.R.I.’s like degenerative disks and arthritis, but these things are very weakly correlated with low back pain,” said study author Dr. Roger Chou, associate professor of medicine at Oregon Health. “We think we’re helping patients by doing a test, but we’re adding cost, exposing people to radiation and people may be getting unnecessary surgery. They start to think of themselves as having a horrible back problem and they stop doing exercise and things that are good for them, when in reality, a lot of people have degenerative disks and arthritis and have no pain at all.”

I completely agree. In addition to unnecessary surgery, they may be getting unnecessary manipulation and other "treatment" which is focused on supposedly misbehaving mesodermal derivatives instead of helping the ectodermal derivatives (i.e., skin, nerves, brain, embedded "I"- illusion) all learn to get along better.

VIRTUAL SYMPOSIUM ON PAIN

This post is about the up-coming webinar series sponsored by the Canadian Physiotherapy Association and its new Pain Science Division (of which I am a exec. member and one of the founders). An internet approach to current, up-to-the-minute meta-education about pain is being integrated into and embraced by the PT profession in Canada, and I couldn't be more happy about it.

I've had a chance to preview the first webinar, and I can assure you the program will shine in both form and content. The content is not overly difficult - it is easy to follow if you have any medical background. Even if you do not, you can take your time with the material and look up the words you don't know with google. Enter the word "define" (but no quote marks) followed immediately by a colon (like this -> :) and the word you want to look up.

For example, if you wanted to look up the word "nociception" to find out the meaning, you would go to google and enter:

define: nociception

Google will take you to a list of possible meanings.

The technical side of the webinar series is speedy and interactive. You can click on pretty much anything from anywhere, from menus listed on the side or as new menus present themselves. Each module will be accessible for an entire week, can be viewed multiple times, and by more than one individual. A discussion forum will operate, where individuals can log in, ask questions, discuss, and help develop answers for other participants' questions, perhaps from their own specialized level of expertise.

Because this is an internet event and is mostly in virtual time, anyone on the planet can participate (if they use English). Only the last (fourth) session will be in real time, probably sometime during the last week of November.

Every conscious human awareness who is embedded in a physically alive body will have to deal with their own pain circuitry at some time or other during their life span. Pain can be hell, but the more prepared we are, the more we can do about our own response to it at the time. Anyone from any walk of life, therefore, is invited. This is the PT profession, reaching out not only to its own members but to the world, offering everyone some well-organized, coherently-presented and useful basic information on a potentially unpleasant matter that either does or will affect us all.

GO HERE TO REGISTER.

Getting past fear

In reference to FABQ and physical therapy:

Cory, I have to confess up front that I've never used this questionnaire with any of my patients.

I completely concur with your conclusion:

Bottom line, change the belief about pain and you change the way a person behaves in response to pain. Change the behavior in response to pain and you can change the pain itself.

This post by Matthias also references Waddell's book and the biopsychosocial model, here.

The brain seems to be attracted to novelty, even if only the novelty of a new idea (it must find the "new idea" nonthreatening of course..). This ties in with Melzack's pain model, where the neuromatrix constantly folds in cognitive evaluative, sensory-discriminative, and motivational-affective inputs, to produce its outputs, one of which might be pain perception.

The other thing the brain finds convincing, possibly even more so, is illusion, whether visual (as with mirror therapy a la Ramachandran, or with videos a la Ehrsson and Lenggenhager and Blanke) or kinesthetic ("movement illusion" as per Collins et al) or perhaps both. (Here's a little study idea I had late last year..)

If the illusion is convincing enough to the brain, it doesn't seem to matter if the "mind" is convinced or not - people seem overwhelmingly capable of suspending any disbelief they may have. The mirror therapy is sufficient proof of that - the amputee patient is fully aware they are looking at their remaining limb move in a mirror image, yet the illusion still works. A large-scale trial of mirror therapy is currently underway at Walter Reed army hospital.

It looks to me like our PT work will just keep on evolving and get easier and easier, the more the brain/ nervous system comes to be understood and appreciated, the more we learn to understand how it perceives and constructs a reality for itself and the human body it is meshed with.

Getting a handle on Back Pain

Here are some good, written-for-the-public, articles on the old topic of back pain and a new high-tech twist on its alleviation. Article 1 is by Jonah Lehrer, author of the blog Frontal Cortex and an editor for Seed Magazine: The Psychology of Back Pain.

The article uses the word "mind"(Christof Koch would probably not approve); however, the gist of it is that if a person with chronic low back pain can access a way to visualize the regions of the brain involved in and perpetuating/fueling the "central sensitization" of the body zone involved, i.e., viewing their own brain on an fMRI screen, they can learn to reduce the back pain in a top-down manner. Excerpt from the last page of the article:

"Christopher deCharms, PhD, a lead author on Dr. Mackey’s paper, is trying to take this therapeutic approach mainstream. He has started a company called Omneuron, which makes the experimental treatment available to a wider audience. A standard session goes like this: A patient lies in a brain scanner while experiencing pain, and he watches as his brain flares up in agony. He sees the smear of neural activity that makes him suffer. Then, with the help of a trained therapist, the patient learns how to consciously turn off the specific brain areas that correlate with the chronic pain. After a few sessions, the awful symptoms begin to fade away. The pain is no longer permanent. It’s a real-world example of mind over matter."

Another general-reader article, called Seeing Your Pain, by Emily Singer, discusses Omneuron's work in a bit more detail.

I found these two articles linked into a thread called "The Psychology of Back Pain", at SomaSimple.com.

Both these articles but especially the second (all the way through) emphasize doing something with basic visualization;

1. Turn attention inward (in this case, with the help of a huge expensive MRI visual feedback machine, which provides an outside, visible "fixation" point; associative "learning" takes place)

2. Create a visible "thought object" (as per Antonio Damasio) to hold in one's attention, in this case a visual image that represents one's "pain" (in this case, it's a red spot on a screen flickering in a part of the brain that brain research has identified as being associated with persistent pain, therefore as close to "real", as closely associated as it's possible to get, probably - boosting the all important "trust" factor)

3. Find ways to "deconstruct" the now-'visible' "thought object", the visualization of the pain, the "source" of it.

I guess this works (finally) for those who can't just go ahead and do a facsimile of this on their own. In fact, I wonder if one could find correlations between low back pain and lack of imagination? Image-ination? Ability to form visual images?

We already know that the brain can't tell the difference between something "real" and something "illusory". It will respond to a sufficiently convincing image and downregulate pain successfully, as Ramachandran's mirror work for phantom limb pain has shown.

MRIs are still pretty expensive to use as feedback devices. As Ian S. pointed out in the thread,

"sitting still and learning to meditate costs $0... I think the interventions are interesting but fit in with the culture of high tech solutions to what are low tech approaches (paying attention / learning to take responsibility / reducing threat )."

Visual Feedback for Backs

Response to Visual Feedback.

Matthias, I can see how treating could be done right now, with the right equipment.. much like your idea about treating paraplegic central pain.
I was thinking of something perhaps a bit more ambitious and potentially devious, however; how one might design a study to determine if back pain could be treated virtually, using these "virtual back" studies as a point of departure.

Think of the possibilities: if it could be shown that back pain/neck pain could be treated visually/virtually instead of being the huge treatment morass it is right now, several ramifications might ensue.

1. Heavy, structurally based manual therapy could potentially be made obsolete in the future. (:D)

2. Potential big cost savings for everyone; patients wouldn't have to suffer as much for as long. Employers would save insurance costs. Insurers would save on disability claims. Aspiring professional human primate social groomers wouldn't feel obliged to pay out huge $ for manual therapy courses of under-studied or dubious quality taught by greedy "gurus".

3. Humans might actually suffer, overall, less low back pain as an industrialized, domesticated species, in the future.

Just some wild and crazy thoughts. Dare to dream I say..