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Letters

Time to change pain paradigms

Fred E. Arthur
CMAJ February 20, 2018 190 (7) E200; DOI: https://doi.org/10.1503/cmaj.733579
Fred E. Arthur
Primary Care Physician, Western University, London, Ont.
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Drs. Traeger and colleagues1 identify the continuing increase in societal costs resulting from low-back pain and associated disability. They provide one explanation: that patients are receiving low-value health services from their primary care physicians and that these physicians also underuse treatments known to improve low-back pain outcomes. The emphasis remains on detecting patients with serious physical injuries, despite that perhaps 1% of patients will harbour a serious injury and most pain-related disability is not predicted by injury severity.3 The implication is that many therapies and investigations cause worsened patient outcomes. This implication remains unproven; other explanations are possible.

The present back pain guidelines do not fit with the natural history of low-back pain in primary care: usually, 28%–60% of patients continue to have persistent pain and disability at one year;2,3 patients with back pain in primary care report high visual analogue scale levels, which reflect an extensive activation of a wide neuromatrix4 with high risk for neuroplastic modification; and at least 30% or more of the variation in disability might be explained by patient distress and magnified illness behaviours at first assessment.5 Yetn intensive biopsychosocial treatments6 and back schools7 provide little disability prevention.

Our patients are in severe pain, with high risk for permanent disability and with a brain activation of a wide neuromatrix of mostly instinctual and emotional centres, and they rightly demand our help. Usually, recommending a hot pack won’t cut it.

We may need to accept that the tissue injury model has failed and that a new paradigm is needed but is so far undeveloped. It will need to reflect the experience of primary care and the known natural history of the condition.8 One suggestion would be to measure the brain activations of actual patients in primary care — instead of asymptomatic university students — and then adjust interventions to these activations. Perhaps it is time for a paradigm change.

Footnotes

  • Competing interests: None declared.

References

  1. ↵
    1. Traeger A,
    2. Buchbinder R,
    3. Harris I,
    4. et al
    . Diagnosis and management of low-back pain in primary care. CMAJ 2017;189:E1386–95.
    OpenUrlFREE Full Text
  2. ↵
    1. Henschke N,
    2. Maher CG,
    3. Refshauge KM,
    4. et al
    . Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008;337:a171.
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Rundell SD,
    2. Sherman KJ,
    3. Heagerty PJ,
    4. et al
    . Predictors of persistent disability and back pain in older adults with a new episode of care for back pain. Pain Med 2017;18:1049–62.
    OpenUrl
  4. ↵
    1. Legrain V,
    2. Iannetti GD,
    3. Plaghki L,
    4. et al
    . The pain matrix reloaded: a salience detection system for the body. Prog Neurobiol 2011;93:111–24.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Waddell G
    . Chronic low-back pain, psychologic distress, and illness behavior. Spine 1984;9:209–13.
    OpenUrlCrossRefPubMed
  6. ↵
    1. Marin TJ,
    2. Van Eerd D,
    3. Irvin E,
    4. et al
    . Multidisciplinary biopsychosocial rehabilitation for subacute low back pain. Cochrane Database Syst Rev 2017;6:CD002193.
    OpenUrl
  7. ↵
    1. Poquet N,
    2. Lin CW,
    3. Heymans MW,
    4. et al
    . Back schools for acute and subacute non-specific low-back pain. Cochrane Database Syst Rev 2016;4:CD008325.
    OpenUrl
  8. ↵
    1. McWhinney IR,
    2. Freeman T
    . Textbook of family medicine. 3rd ed. New York: Oxford University Press; 2009.
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Canadian Medical Association Journal: 190 (7)
CMAJ
Vol. 190, Issue 7
20 Feb 2018
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Time to change pain paradigms
Fred E. Arthur
CMAJ Feb 2018, 190 (7) E200; DOI: 10.1503/cmaj.733579

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Time to change pain paradigms
Fred E. Arthur
CMAJ Feb 2018, 190 (7) E200; DOI: 10.1503/cmaj.733579
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