EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

Last month in this column I wrote about the CDC (MMWR. June 18, 2010/59(23);705-709) taking a strong position against the increasing “non-medical” use of prescription drugs (opioids and benzodiazepines) for the relief of pain. I was fascinated by the use of the term “non-medical” use but after I digested their meaning (i.e. more than recommended doses); I realized similar terminology may fit other common problems. Hence, the term “Non-Medical Low Back Pain.” There is no ICD-9 code for this entity; it is not a diagnosis, it is a term to be used for discussion purposes only. Non-medical pain may occur in locations other than the low back pain, but low back pain is the most common.

Let me define my use of the term: low back pain and dysfunction that persists beyond the expected healing time for a common injury/trauma/insult. This is an extension of the ODG chronic pain definition – “any pain that persists beyond the anticipated time of healing.” Non-medical low back pain may be differentiated quite easily from chronic pain. Chronic pain implies 3 – 6 months of pain, usually 6. Non-medical low back pain may be noted within a month of an injury. I believe it is important to correctly label non-medical low back pain early to prohibit inappropriate, aggressive medical treatment.

An example of non-medical low back pain: a healthy adult lifts an object at work and soon after the incident complains of low back pain. The pathophysiology of such an injury (using a medical model) justifies, at most, a few days of rest, conservative medical care, and resolution of symptoms within a few weeks.

The medical model plays out perfectly for motivated patients that either must work to provide their income, e.g., mom and pop store proprietors or well-paid athletes. Witness the recent World Cup for evidence of significant musculoskeletal injury that quickly resolves.

What does this mean? Well, for starters, to treat non-medical low back pain with powerful medications, injections, or surgery is doomed and makes no sense. Instead, biopsychosocial issues and job satisfaction must be addressed, i.e., focus on the patient and their world rather than tissue pathology. Rather than throw medical therapeutics and diagnostics at the patient, it is better to address the psychological state, cultural background/belief system, and relationship/interactions with the environment (workplace satisfaction, home and family dynamics, disability income, and health care providers). And the sooner this is done the better!

Not labeling this entity appropriately often leads to unrealistic patient expectations unwittingly fostered by healthcare providers or others, and predictably leads to treatment failures, delayed recovery, and unnecessary disability and costs.

While the above is a simplification of a very complicated problem, I believe it is very important to recognize non-medical low back pain and treat it accordingly as soon as possible once this “diagnosis” is made. The term implies medical care should be supportive, conservative, and meet the standards of evidence based medicine. Appropriate therapies might include short-term chiropractic, physical therapy or acupuncture care, conservative analgesic medication, home exercise program, and very careful monitoring of functional improvement.