The current approach to musculoskeletal pain is failing
The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability. We contend this has resulted in two concerning developments in the management of people with such disorders. First, structural changes observed on imaging that are highly prevalent in pain free populations, such as rotator cuff tears, intervertebral disc degeneration, labral tears and cartilage changes, are ascribed to individuals as a diagnosis for their condition. In this context, this information may result in the individual believing that their body is damaged, fragile and in need of protection, resulting in a cascade of movement and activity avoidance behaviours and seeking interventions to correct the structural deficits.1 This trend has led to exponential increases in elective surgery rates and associated costs, while the efficacy of repairing (eg, rotator cuff and medical meniscal tears), reshaping (eg, subacromial decompression) or replacing (eg, lumbar intervertebral discs) the structures considered to be at fault has been substantially challenged.2–10Second, it is arguable that musculoskeletal clinicians have invented treatments for conditions that may not exist or be readily detected (such as trigger points, sacral torsions), and they have developed and perpetuated treatment paradigms (such as ‘correcting’ upper body posture and muscle imbalances) that do not conform to current research evidence.11–14 These two trends have created an expectation that interventions (frequently ‘passive’) will provide a ’cure’, and typically quickly, with minimal self-contribution. This expectation may have been derived from a conversation with a friend or family member, from the Internet or from an advertising campaign, but almost certainly originated from health professionals.
Body in Mind blog post: https://goo.gl/qzpQJJ
For at least two decades, we have known that for chronic pain conditions there is discrepancy between tissue damage seen on clinical imaging and clinical presentation. You can have a severely osteoarthritic X-ray with no pain, or a completely normal X-ray with severe pain. Despite this disparity, imaging findings, such as meniscal tears, rotator cuff tears and degenerative discs are often interpreted as causes of pain, triggering medical and surgical interventions. But given the disconnect with actual symptoms, it is perhaps not surprising that interventions to remove/fix the tissue or targeting tissue regeneration, such as arthroscopy, stem cells or platelet rich plasma, are often no more effective in reducing symptoms than sham treatments .
In light of growing concern of overdiagnosis, our recent systematic review and meta-analysis of 63 studies of 5,397 completely asymptomatic uninjured knees revealed that knee osteoarthritis features assessed on MRI (cartilage defects, meniscal tears and osteophytes) were common (up to 60% in those aged >60 years) . Their prevalence, instead of being associated with pain, was closely linked to age. A majority of these features, when assessed clinically, should be viewed like wrinkles on the skin – a normal part of aging that don’t typically require ‘fixing’.
One might theorise the reverse relationship, that even if osteoarthritis presence doesn’t predict pain, pain presence might predict progression of osteoarthritis. Surprisingly, that theory was also refuted in our recent longitudinal study that followed up patients with imaging 15 and 20 years post-anterior cruciate ligament reconstruction . Neither the presence, nor persistence, of patellofemoral pain in the years post-operatively predicted any significant difference in patellofemoral osteoarthritis 15-20 years later.
Pain and related disability are normally the primary concern for patients seeking treatment. The persistence of pain experience in response to mechanical stimuli is often thought to indicate adverse tissue loads from a biological perspective, leading to interventions aimed at tissue ‘offloading’ to prevent injury or degeneration. Counterintuitively, offloading tissues in the context of musculoskeletal pain may be more problematic than beneficial for tissue health. For example, following acute knee injury, which places young adults at high risk of early-onset knee osteoarthritis, those who actually developed osteoarthritis walked with lower peak knee contact forces (2.10 x body weight) than those who didn’t develop osteoarthritis (2.89 x body weight) .
Furthermore, one-third of adolescents who develop patellofemoral pain are sedentary . In addition to the potential for mechanotherapy (ie. promotion of tissue repair/remodelling with exercise-therapy) , tissue loading through exercise can also have acute sensory effects – improving pain by reducing a sensitised nervous system through a reduction in cortical inhibition . It is important to remember that clinical changes occur beyond the resolution of imaging and/or tissue mechanical properties.
Pain can persist with safe tissue loads. Even when persistent pain displays ‘mechanical’ behaviour, this could represent the early or unnecessary warnings from a sensitised nervous system, as much or more than any threat to tissues. For example, patellofemoral pain, often considered mechanical in origin with greater pain in activities that apply greater load to the knee, is characterised by local and widespread hyperalgesia indicating a combination of peripheral and central mechanisms driving pain . Approaches to pain management therefore need to consider more than just mechanical effects of altering tissue load, because positive adaptations knock-on to affect other domains. Exercises with gradual progression of loads, intended for mechanotherapy can also be viewed as neurosensory-therapy (modulating sensitisation and motor control) as well behavioural therapy (modulating thoughts and feelings related to body use).
Pain should not typically be a barrier for tissue and joint loading, but it is an important clinical consideration when planning how much load will provoke a sensitised nervous system. For example, for patients with chronic knee and hip pain, a program of progressive loading (strengthening) resulted in sensory adaptations leading to a considerable decrease in exercise-induced pain flares . Even in acute injury settings, where traditional first-line injury management was rest (the R in RICE), guidelines have now shifted and advocate ‘protect and optimally load’ (the POL in POLICE) .
There is need for vigilance but not fear of gradual progressive loading interventions for people with persistent musculoskeletal pain. The potential acute benefits for the sensory nervous system, the long-term benefits on tissue mechanical properties and minimising degeneration, as well as the general health benefits are all valuable. Even in the presence of persistent musculoskeletal pain, gradual progression of tissue loading through exercise is likely to be more friend than foe.
ORIGINAL ARTICLE HERE: https://goo.gl/DdPtah
Exercise and movement may be the best medicine for back pain.
You might be considering surgery or other intervention to treat your back pain. But less may actually be more for this common problem, and in many instances the best medicine is good old-fashioned movement and exercise.
The enigma of back pain
Back pain is one of the most common medical problems in the United States, according to the National Institutes of Health. It's also a little strange as far as ailments go.
When you twist your ankle, you generally have pain that slowly goes away as the injury heals. Not so with back pain. Relief doesn't seem to be linked to healing because the pain is usually unrelated to an injury. In fact, back pain often diminishes over time, even when there is an underlying problem like a herniated disc or arthritis, says Dr. James Rainville, assistant professor of physical medicine and rehabilitation at Harvard Medical School.
Adding to the mysteries of back pain is the fact that people tend to report more back pain in their 40s and 50s than they do as they get older. But back degeneration generally increases over time, so logically, people should have more pain — not less — as they age.
In addition, as many as 80% of adults report at least one episode of back pain. The other 20% never experience back pain at all. But it's not because their spines are normal. Imaging tests on these pain-free folks show as much degeneration in their lower spine as everyone else has, says Dr. Rainville. The question is, why don't these changes seen on imaging cause them pain?
The oddities of back pain are likely due to the fact that a neurological healing process — not a physical one — is at work, says Dr. Rainville. As the theory goes, when a problem occurs and triggers pain, it's your nervous system that actually adapts to the pain, and that's what makes discomfort go away, says Dr. Rainville. Exercise and movement may help your nervous system to make this adjustment more rapidly.
Understanding back pain
Degeneration in your spine is a natural part of aging. "A bulging disc, in some ways, is no different than the wrinkle next to your eye," says Dr. Rainville.
Contrary to what many people believe, only rarely does back pain strike while someone is lifting something heavy or performing an intensive activity. "In cases of new-onset disc herniation or sciatica, only 5% of people were doing anything considered heavy physical exertion, like lifting an air conditioner," says Dr. Rainville. Those things are rare. Most people are doing simple tasks, such as leaning over to spit in the sink when brushing their teeth. "I commonly hear things like, 'I was just reaching for a pencil,' or 'I sneezed,'" he says.
Back pain most often results from inevitable tissue failure caused by age-related deterioration. "There is no evidence that being careful will slow the process of disc degeneration down," says Dr. Rainville. After all, being careful won't stop any other signs of aging, such as wrinkles or gray hair.
The genetics of back pain
Your experiences with back pain may have a lot to do with your individual genetic makeup. "The symptoms associated with back pain are highly variable," says Dr. Rainville. "Pain can last anywhere from a day to three months."
And just as some people are prone to heightened pain — which may occur in people with conditions such as fibromyalgia — some people are at the opposite end of the spectrum and less prone to pain.
Research has shown that the tendency to experience more or less back pain runs in families. For example, identical twins often have similar histories of back pain, says Dr. Rainville. This is the case even if they have completely different lives and experiences — for example, if one twin has a desk job and the other performs heavy labor in construction. "These things are likely highly genetic," says Dr. Rainville.
Strategies to help back pain
The National Institute of Neurological Disorders and Stroke recommends several strategies to help ease back pain when it flares up:
Changing attitudes about back pain
While back pain may be inevitable for many people, changing attitudes about the problem could be making it worse. In the past, people used to take back pain in stride and didn't generally seek medical help. "It's only really been over the past 30 years that more and more people have been seeking health care for back pain," says Dr. Rainville. But that hasn't reduced the prevalence of pain or disability. In fact, disability from back pain has actually increased over time.
In 1990, a study ranked back pain as the sixth most burdensome condition in the United States. In 2010, it jumped to third place, behind only heart disease and chronic obstructive pulmonary disease, according to the National Institute of Neurological Disorders and Stroke (NINDS).
Where back pain was once viewed a nuisance to work through, today, back pain stops many people in their tracks. "People have gotten stuck because they've been given the advice to be careful and stop moving," says Dr. Rainville. "This runs counter to everything that was taught for decades."
Many doctors are encouraging a return to the past when it comes to managing back pain, with less emphasis on intervention and more on encouraging movement.
Treating back pain
Movement seems to be the stimulus to normalize pain responses in the nervous system. Studies on animals with spinal injuries show faster pain resolution among those forced to exercise than among those allowed to move less, says Dr. Rainville.
"This is probably the result of a survival mechanism," he says. "If an animal in the wild doesn't get moving, it is eaten or starves to death." Movement also seems to help people. "People who get moving — back to the gym, back to cleaning the house — do the best," says Dr. Rainville.
Surgery may be necessary for some back problems, such as conditions that are causing progressive nerve damage or that involve structural changes that need to be corrected, according to the NINDS. "But in a lot of cases it's less justified," says Dr. Rainville.
So, if you're experiencing back pain caused by normal wear and tear, the message is that in most cases you don't need to stop your life and wait to heal. Move your body instead.
Physical therapists can play a role in helping you gradually and safely increase your activity level, to desensitize your nervous system's response, so you can get back to your regular daily activities.
Needless procedures: knee arthroscopy is one of the most common but least effective surgeriesIan Harris, UNSW; Denise O'Connor, Monash University, and Rachelle Buchbinder
From time to time, we hear or read about medical procedures that can be ineffective and needlessly drive up the nation’s health-care costs. This occasional series will explore such procedures individually and explain why they could cause more harm than good in particular circumstances.
More than 70,000 knee arthroscopies were performed in 2011 in Australia and, though rates of the surgical procedure are now falling, it still remains one of the most common surgical procedures.
The word arthroscopy means to look inside a joint, in this case the knee. But newer imaging techniques, such as magnetic resonance imaging (MRI) scans, mean performing a knee arthroscopy simply to look inside the knee joint is rare.
Knee arthroscopies are most commonly performed to treat osteoarthritis (wear and tear in the joint) or problems with the menisci (the two rubbery discs between the bone ends). An arthroscopy involves making a small incision in the skin and inserting a kind of camera on a stick. Another incision is made to insert other instruments to cut and remove tissue.
In the case of osteoarthitis or meniscal problems, arthroscopy can be used to clear debris from the joint or to trim loose cartilage or torn parts of the menisci. The procedure can also be used to perform ligament reconstructions, help with treating fractures or infections in the knee, or simply to take a sample of tissue from the joint.
The camera can see structures such as the cartilage that covers the end of the bones, the lining (synovium), the menisci and ligaments. Knee arthroscopy requires admission to hospital and an anaesthetic. It carries some risk of harm such as infection or further damage in the joint.
It’s rarely effective
Most knee arthroscopies are done in older people for degenerative conditions such as osteoarthritis. The prevalence of knee osteoarthritis, which can involve wear and tear of the menisci as well as the cartilage that lines the bone, increases with age. Most people aged 50 years and over have some osteoarthritis in the joint and roughly one-quarter will have some wear and tear in the menisci.
Many people with osteoarthritis or a torn meniscus also have knee pain. This has led to the belief that the osteoarthritis changes or the meniscus tear cause the pain. But these changes are also common in those who have no pain at all. And menisci mostly don’t have nerves, so they can’t be felt unless there is a large tear, often resulting from a major injury. In fact, most people with a torn meniscus don’t have knee pain.
Many studies have now shown the outcomes from arthroscopic surgery for osteoarthritis and degenerative meniscal tears are no better than the outcomes from placebo (fake) surgery or other treatments (such as exercise therapy).
A recent summary of these studies made “a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease” (osteoarthritis and degenerative tears of the menisci) and concluded “further research is unlikely to alter this recommendation”.
Many surgeons believe the presence of mechanical symptoms – a concept that is not clearly defined but involves pain and abnormal feelings (such as catching, clicking and locking) when moving the joint – can be treated with arthroscopy. However, studies have also shown having arthroscopy does not provide better results than fake surgery for the treatment of mechanical symptoms.
Sometimes, a meniscus can be so badly torn it folds over on itself, jamming the knee and restricting the ability to straighten the knee. This is a relatively uncommon type of meniscus tear and if the symptoms don’t improve on their own, the torn part of the meniscus can be removed arthroscopically.
Why do surgeons still recommend it?
Doctors tend to overestimate how good their treatments are and underestimate the harms that come from them. Surgeons are often faced with patients in pain and, other than surgery, have little else to offer except continued non-operative treatment, reassurance and time.
Patients may want a quick fix or may have failed to improve with other treatments, but unfortunately the failure of other treatments doesn’t make knee arthroscopy any more successful.
Knee pain due to osteoarthritis often fluctuates in severity and patients tend to present for treatment when their pain is most severe. This means any treatment given at this time will appear more effective than it truly is. This is why comparative studies, particularly placebo studies, are important, as these show the true effects of treatments.
Though some surgeons may believe they can predict which patients will do well from surgery, this belief has not been validated. Despite the desire for this procedure to work, arthroscopy for degenerative knee conditions puts patients at risk of harm, including death, for no important benefits.
How can we stop it?
Changing practice in response to evidence is often slow. The first high-quality trial to demonstrate knee arthroscopy was no better than placebo surgery was published in 2002, yet overuse of knee arthroscopy has persisted.
The rates of knee arthroscopy in Australia are starting to fall, particularly in New South Wales, where the rate of knee arthroscopies in people aged 50 and over has nearly halved since 2011. More action is needed. All surgeons, particularly in high-volume states such as Western Australia, South Australia and Victoria, need to take a good hard look at the evidence, question their practice, and take action to reduce this overuse.