Evidence-Based Approach to Back Pain

People in pain don't want a trial-and-error approach to treatment. They need an evidence-based treatment plan that is going to work right from the start. One way to achieve this is by identifying subtypes of pain -- in other words, what's nerve-related (neuropathic) and what's not? No sense treating pain with an approach that doesn't even get at the underlying pain mechanisms. We know that can be a waste of time and money.

Dr. J. Scholz, a neurologist at Harvard Medical School (Boston, Massachusetts) is leading the way in this approach. He has developed and tested a bedside tool called the Standardized Evaluation of Pain or StEP. It is a highly sensitive and specific test for telling the difference between neuropathic and non-neuropathic pain.

Who might benefit from this type of test? Anyone with chronic pain from diabetes, herpes, or spinal nerve root compression. A study was done with a special focus on patients with chronic low back pain from radiculopathy. Radiculopathy refers to compression of the spinal nerve root (usually from a herniated disc) causing back pain that travels into the buttock and sometimes down the leg.

By testing patients for signs and symptoms and asking a set of specific questions, it was possible to see distinct patterns to separate neuropathic pain patients from those suffering from non-neuropathic pain. After analyzing the data and coming up with six subgroups of neuropathic pain patterns and two of non-neuropathic pain, the author was able to refine the StEP test.

It all boiled down to six questions to ask patients and 10 simple physical tests to give each patient. By administering the StEP test, they could at least tell which patients were suffering from nerve-derived pain and who was not. The next step is to find which treatment approach works best for each of the subgroups identified in this study.

Researchers believe that a better understanding of the exact mechanism producing pain will improve the chance of success in treating chronic pain patients. The target of therapy should not just be masking pain but should go right to the active mechanism causing the pain and put a stop to it.

While others continue to use the hunt and peck method of pain control (try this, try that, see what works), Dr. Scholz has come up with a way to assess patients' pain accurately early on. That will ultimately help pain experts predict what patient responses will be to specific treatments. Choosing a treatment right from the start that has a high chance of success is the ultimate goal in pain management.

Alice Goodman. Simple, Fast Tool Provides a StEP Up in Back Pain Diagnosis. In Pain Medicine News. June 2009. Vol. 7. No. 6. Pp. 6-7.

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