What The Duke Acccuser Should Learn About Back Pain

    I thought this recent article below from Medical News Today was interesting. It reinforces what I was saying earlier that, given time, most back pain problems heal on their own, without the need for long term muscle relaxants or narcotics.

Does that mean that there are no flare ups, no aches and pains on and off? No. As a sufferer of chronic low back pain for over twenty years, I can attest to that.

   However, when it acts up, I don't take any medicine, other than the occasional over the counter relief, along with heat, massage, and rest.

  My aches and pains and the treatment for them are pretty typical of most people who suffer from chronic back pain.

I only took a muscle relaxant once and never took narcotics. Narcotics are usually not the way to go when dealing with chronic low back pain. 

   In fact, the government keeps very close tabs on prescriptions given for schedule II drugs like Percocet, requiring strict compliance with the Controlled Substances Act (CSA) of 1970.

   It's actually gotten to the point where many private physicians are leery of prescribing narcotics, even when it may be justified. 

Schedule II drugs

Findings required:

(A) The drug or other substance has a high potential for abuse.

(B) The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.

(C) Abuse of the drug or other substances may lead to severe psychological or physical dependence.

These drugs are only available by prescription, and distribution is carefully controlled and monitored by the DEA. Oral prescriptions are not allowed except in emergencies, and no refills are allowed. Also, Schedule II drugs are subject to production quotas set by the DEA.

Drugs on this schedule include:

• Cocaine (used as a topical anaesthetic);

• Methylphenidate (Ritalin);

• Phencyclidine (PCP);

• Most pure opioid agonists: Pethidine (INN) or Meperidine (USAN), Fentanyl, Hydromorphone, Opium, Oxycodone (the main ingredient in Percocet and OxyContin), or Morphine;

• Short-acting barbiturates, such as secobarbital;

• Amphetamine was originally placed in Schedule III, but was moved to Schedule II in 1971. Injectable methamphetamine has always been in Schedule II;

 

    Those who engage in drug seeking behavior, or "doctor shopping", often hit the various emergency rooms, complaining of extreme pain, hoping to get a physician to prescribe the drug.

     I've often wondered why the accuser went to UNC Hospital rather than just go right back to the SANE unit at Duke. Part of the standard discharge instructions given to our patients is to instruct them to call or return to the ER or SANE unit if they have any further problems or bruising showing up.

   We tell them, we can always take more pictures. So why didn't she go back there? If I missed it, I'm sorry, but I don't recall reading anywhere that she did. Of course, our physicians don't usually give out prescriptions for pain medicine. Not that they can't, but most patients don't need it. 

    On the flip side of that though is the fact that should a patient be in "extreme pain", of course the physician may write a prescription, if they believe it's necessary. Medical treatment of our patients always takes priority before the SANE exam.

   The accuser showing up at UNC the next day indicates to me that she did not receive a prescription at Duke, even though she supposedly was in "extreme pain."

Waddell's Eight Point Check List

In order to determine if the patient's symptoms are the result of a true physical cause or are actually non organic, there is a test called Waddell's eight point test which can be done during a normal exam.

   It's been shown that if the patient tests positive for three or more check points, then their symptoms are suggestive of non organic behavioral causes, such as psychological issues or malingering.

Table 2. Waddell signs for identifying nonorganic causes of back pain*
Sign	Positive finding
Superficial tenderness	Skin discomfort on palpation
Nonanatomic tenderness	Tenderness that crosses multiple somatic boundaries
Axial loading	Report of low back pain
Simulated rotation	Report of back pain
Distracted straight-leg raise	Report of pain in low back or posterior thigh; lessening of pain with continued leg raising; severe pain at 10° flexion in patient with no apparent disability
Regional sensory change	"Stocking" or global distribution of numbness
Regional weakness	Sudden, uneven weakness (eg, "cogwheeling," "dithering") in patient with normal strength on muscle testing
Overreaction	Exaggerated, nonreproducible response to stimulus

   One of the things I found interesting when reading of the accuser's back pain, as described by Sergeant Gottlieb, was what appeared to be exaggerated movements and symptoms.

   Supposedly, she was limping, grimacing, crying, and couldn't sit down - shifting from one side to the other - not able to sit on her buttocks.

    At first glance, her symptoms seemed to possibly indicate a herniated disc. Ordinarily, with a herniated disc, there can be limping with acute pain, as the pain radiates down the sciatic nerve into one leg. People can also have trouble sitting or standing in one position for any length of time. I had that problem myself years ago.

    However, I never had any problems actually sitting down. One other thing about true herniated discs: You can't do straight leg raises. It causes extreme pain due to compression on the nerve.

   For those who haven't seen the Inside Edition video that supposedly shows the [very limber] accuser doing a marvelous squat and leg lift, take a look:

   Pole Dancing Video

In addition to problems with leg lifts, studies have shown those with lower back pain have a significant problem with flexion and movement of the hips and lower back. Here are a three studies:

   Spine
   "RESULTS: The mobility of the spine and hips was significantly limited in back pain subjects. It was observed that LBP subjects employed various strategies to compensate for the limited motions at the hips and lumbar spine."

   Forward Movement
   "CONCLUSIONS: When assessing the relative motion of the lumbar spine and hips in standing forward flexion, there was measurable difference between asymptomatic men and a group of chronic low back pain patients.

   Symptomatic movement in lumbar spine and hip
   "RESULTS: Mobility was significantly reduced in back pain subjects. Symptomatic subjects compensated for limited motion through various strategies, but in all cases the contribution of the lumbar spine relative to that of the hip was significantly reduced. The lumbar spine-hip joint coordination was substantially altered in back pain subjects ..."

     According to Waddell, one of the biggest signs of non organic pain is the distracted straight leg raising test. If the patient knows they are being checked, the leg test will be positive. If the patient is distracted or doesn't realize they are being checked, the test is negative.

   Another sign of behavioral causes are exaggerated symptoms and continued complaints of extreme pain (8 - 10/10) with no obvious physical basis for the pain.

     I still remember what it was like right after I developed a herniated disc - which was confirmed with an MRI. I couldn't have done a straight leg raising test to save my life - much less do any kind of pole dancing!

                                    

Back Pain--when To See A Doctor

Main Category: Pain / Anesthetics News
Article Date: 23 Oct 2006 - 0:00am (PST)
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   Some 70%-80% of men (and nearly as many women) have endured a bout of moderate to severe back pain. And the problem goes well beyond pain and inconvenience; the annual cost of medical care and lost productivity is more than $50 billion. It would be encouraging to report that this investment of time and money results in recovery, but in most cases back pain will resolve as quickly without medical attention as it will with a doctor's care, according to the November 2006 issue of Harvard Men's Health Watch.

If you have garden-variety back pain, you can probably take care of it yourself. The trick is to know what to do and to recognize those symptoms that really do call for prompt medical tests and treatments. To help you help yourself, the November issue of Harvard Men's Health Watch contains a special supplement on back exercises.

In the vast majority of cases, back pain is caused by a mechanical problem that can't be pinpointed exactly. But occasional cases result from some other, more serious causes. The possibilities include infections, vascular disease, and tumors, among other things. That's why it's important to know the “red flag” warning signs that suggest serious problems. Among these are recent major injury, radiation of pain down a leg, pain that is constant, pain in the upper back or chest, unexplained fever or weight loss, and pain that increases at night.

About 90% of people with ordinary mechanical low back pain get over it without special therapy. But it takes time to recover. About 30% of patients are substantially improved in just a week, but another 60% take up to eight weeks to get better.

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