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Study Explores Myths of Chronic Back Treatment
http://www.hopkinsneuro.org/brain_tu..._Back_Pain.htm

Long and BenDebba at LBP's source.

Massages, analgesics, nerve blocks - things patients with chronic low back pain try to sidestep surgery - are essentially no help at all, says experimental psychologist Mohammed BenDebba, Ph.D. "And if you factor in the cost of such treatments, these conservative approaches - even for patients awaiting surgery - are probably a bad idea."

For 10 years, neurosurgeonDonlin Long, M.D., Ph.D., and BenDebba headed the National Low Back Pain Study, a project which followed 2,374 LBP patients seeking help from neuro or orthopedic surgeons expert in spinal disorders. Now researchers are spinning off studies like this one on the outcomes of clinicians’ choices for chronic low back patients several years after treatment. Beside downplaying conservative treatment, this work has cast doubt on ideas held sacred in treating lasting LBP.

Clinicians at Hopkins and seven other tertiary care centers followed patients whose pain stretched on six months or more. Some received no treatment, some conservative care, and some immediate or delayed surgery. Patients in a fifth category were advised against surgery but had it anyway, outside the study.

For two years, patients reported on their pain, after following the specialists’ treatment, and on quality of life. The researchers also tallied patients’ psychological state, physical symptoms and how often they’d sought follow-up medical help.

"Our most impressive finding centers on the surgery," says Long. "Patients receiving a discectomy, laminotomy or other surgery improved strikingly. People not advised to have surgery who had an operation anyway did poorly." But timing appears important. Perhaps because of continuing nerve compression, patients who had to postpone surgery more than three months didn’t fare as well as the immediate surgery group. They still did better, though, than the "outside surgery" patients.

One surprise was that subjects sorted into two psychological profiles. Some chronic LBP patients have "a life dedicated to their illness," BenDebba explains. Pain becomes a consuming event and relief of it, a Holy Grail. They’re the chronic failed back patients.

A second group "carries on their lives as if nothing has happened." Despite pain, they aren’t obsessive or psychologically traumatized and don’t wrongfully use healthcare. BenDebba calls them "persistent" LBP patients. Traditionally, clinicians have put the majority of people with chronic pain into the former category. "But how long a patient is in pain isn’t a criterion for who should be treated psychologically," he says. It’s worth the effort to sort out the two groups, he adds, because, unlike failed back patients, eligible persistent pain patients show more benefit from surgery. And the chronic "failed" patients do better in a multidisciplinary program that addresses psyches as well as pain."Now," BenDebba muses, "if we can just figure out who they are from the beginning."