jama Archives - Minnesota Physical Medicine Blog

Years ago when first entering into the world of medicine, I thought that if a study appeared in a leading scientific journal then it would have to have been a good scientific study. As an undergraduate and in my medical student years I was never really taught how to read a paper and analyze it for its quality. Over the years more articles stopped making sense, and as one would delve into the details, it often became clear that many studies that were published were just bad research.

Often if one knew something about the subject being studied, either the conclusions were obvious or they were not clearly defined such that the answer found may not really have a true correlation to the problem. Good medical studies are often very hard to perform. If you are not very careful, the answer will be junk, even if it is published in a good medical journal. Recently, this has occurred in a major medical journal.

Insurance Sponsored Studies

A recent study in the Journal of the American Medical Association (JAMA) was published with the finding that radiofrequency lesioning does not work in the lumbar region. Unfortunately, this again was a seriously flawed study and on top of everything from a research perspective, it was an insurance sponsored product. The pain societies across the world have been surprised and highly critical of the poor quality of the research and conclusions drawn in this paper.

If one has done their research, they would see that there are multiple excellent studies supporting the use of radiofrequency techniques for some specific uses. This technique has been around since the 1970’s and good equipment and understanding was established in the 1990’s. The technique is very successful for removing a nerve pathway for sensation feedback from facet joints. The science has been proven in detailed and has benefited thousands of pain sufferers. It is a common treatment for facet pain in both the neck and lumbar region and is highly successful when diagnostic blocks done first are indicative of pain relief.

This type of intervention has also been used for a number of other things including knee joint problems, sacro-iliac joint pain, and a variety of peripheral nerve problems and lumbar disc issues. All the other areas treated have had less success due to complex nerve locations. Lumping all radiofrequency treatments together and saying that they do not work is a true disservice to medicine and the patients. Further, since the JAMA is a highly regarded journal, the editors should have more closely scrutinized the study for its validity. Understanding the anatomy in the body also makes a huge difference; nerve location for most areas of the body can be highly variable from person to person and therefore it may be difficult to be successful in severing a nerve with limited ability to visualize its location.

Pain is a very complex sensation in the human body. The overall perception of the stimuli is based on the interpretation of signals in the brain. The brain may actually be receiving signals from multiple structures but interpreting them all as similar and from one location. Eliminating one piece of the signal may be sufficient to solve a pain problem. If the signals are coming from multiple locations, eliminating just one part of the signal may not change the brain’s perception of pain. The joints along the spine have very well defined sensory nerves and feedback; If the pain is from this structure it can be clearly determined and successfully treated. The discs and sacro-iliac joints have poorly defined sensory feedback, trying to eliminate the signals from these regions is still a matter of study. If the editor of JAMA used some critical thinking, the poor quality of the study would have been easily seen and the disservice of its publication could have been avoided.

Radiofrequency management of pain can be highly successful. It is definitely a science with some very technical variables that impact its success. To use this as a tool in pain management, understanding its science, capabilities, risks and benefits is necessary. It is well proven to work in certain situations. A good clinician can maximize radiofrequency effectiveness for a variety of problems but it does have limits. It is not experimental but it does have its inherent challenges in its ability to safely remove enough nerves to relieve pain. If you have pain, a good board certified pain physician can often help a patient find strategies that may lead to more successful management of your symptoms.

Understanding Opioid Addiction

Opioid addiction is a significant issue today. Yearly over 30,000 people die due to opioid-related incidents. This is nearly as many people as those who die in automobile accidents. However, addiction is an illness in itself, and of all the people who use opioids, only a small percentage of about 5-7 percent at most ever become addicted. Addiction to opioids is no different then other addictions and requires psychological intervention and medical detoxification.

Chronic pain is a very complex disease, and has many causes. There often is not a single problem involved and finding solutions to improve the issues present takes a deep medical understanding of many different fields. One must be able to identify and understand all the medical problems contributing to pain. Having a solid knowledge of rheumatology, internal medicine, orthopedics, neurology, and musculoskeletal medicine are just a few of the skills needed in pain medicine. In reality, it does not matter how people progress to a chronic pain condition, what matters is that 1/3 of the adult population has problems with chronic pain.

The article in JAMA recommends that primary care physicians need to see the pain patients frequently, with shared decision making, compassionate care, promoting shared decision making, and use an interdisciplinary approach. They should work with motivational interviewing, and have physical therapists and psychologists in the office to work with them and the patients.

This article was written by physicians from the University of Michigan, and pardon my language, is crap. From experience, these physicians are in academics and they are tremendously sheltered from the pressures of most practice situations. Most primary care physicians have 15 minutes at the most to see a patient and they do not have any other support like psychologists in their practice or physical therapy. At the University of Michigan, pain patients are also referred out to the Physical Medicine physicians. The advice in this article is of extremely low use.

What We Should Be Doing

Primary care physicians need far more practical advice on management of chronic pain. First off, chronic pain is not a single medical condition but most commonly it is the response to multiple medical problems. The role of primary care medicine is, more importantly, to identify that there is a problem and help quarterback and guide a patient to the correct treating physicians. With limited time for each visit, send the patient to experts in pain management such as a physical medicine physician who actually has the appropriate training and resources to treat complex problems.

Secondly, avoid the quick fix by trying to hand out medication, especially opioids and many of the other drugs on the market since developing a comprehensive management strategy is necessary. Again this type of management is not really primary care and working with a specialist is more productive. Once a specialist has developed a successful treatment approach, be willing to take over and maintain the program. Third, realize pain is extremely complex, often with no cure, and the goal of treatment is to improve function and make the symptoms more manageable. The best advice for primary care physicians is to learn who are the knowledgeable and successful pain management experts in your area and use their expertise to help manage these complex patients.