Page 223 Guide to Pain Management in Low-Resource Settings

Chronic Nonspecifi c Back Pain 211

joint provokes pain with variable local and referred pain In cases of progressive neurological defi cit, imaging
patterns into regions of the buttock, lower lumbar area, should be done without losing any time, when imaging
lower extremity, and groin. Certain maneuvers (e.g., Pat- is available, or the patient can be transferred to a loca-
rick’s test) may provoke typical pain, too. Local blocks tion where imaging is available. Plain anteroposterior
sometimes accelerate recovery and facilitate physical and lateral lumbar spine radiographs are indicated fi rst
therapy. In young male adults in particular, Bechterew for identifying cancer, fracture, metabolic bone dis-
disease (ankylosing spondylitis) has to be ruled out. ease, infection, and infl ammatory arthropathy. In these
diseases, more sophisticated (and expensive and rare)
Muscular pain
further diagnostic imaging will not add substantial in-
Muscular pain is most often the cause of chronic back formation for most patients. CT scanning is an eff ec-
pain. Pain receptors in the muscles are sensitive to a vari- tive diagnostic instrument when the spinal and neuro-
ety of mechanical stimuli and to biomechanical overload. logical levels are well identifi able and bony pathology
Anxiety and depressive disorders often play an important is suspected. MRI is most useful when the exact spinal
role in sustaining muscular pain due to the “arousal re- and neurological levels are unclear, when a pathological
action,” with a continuous increase of muscular tension. condition of the spinal cord or soft tissues is suspected,
Muscular pain may be described as “myofascial pain,” if when disk herniation is possible, or when an underly-
muscles are in a contracted state, with increased tone and ing infectious or neoplastic cause is suspected. If in-
stiff ness, and contain trigger points (small, tender nod- terpretation of MRI or CT scans is diffi cult and nerve
ules that are identifi ed on palpation of the muscles, with root or myelon compression is suspected clinically, my-
radiation into localized reference zones). In most patients elography may be useful to get a clearer picture, espe-
myofascial pain is the result of a combination of factors: cially in patients with previous lumbar spinal surgery or
the “arousal reaction,” direct or indirect trauma, exposure with a metal fi xation device in place. Non-radiographic
to cumulative and repetitive strain, postural dysfunction, tests include electromyography (EMG) and somatosen-
and physical deconditioning. sory evoked potential testing (SEP) and help to local-
On the cellular level, it is presumed that abnor- ize nerve lesions and to diff erentiate between older and
mal and persistently increased acetylcholine release at the newer lesions.
neuromuscular junction generates sustained muscle con-
traction and a continuous reverberating cycle. If muscu- Th erapeutic approaches
lar back pain does not resolve within a few weeks (usu-
ally 6 weeks is seen to be crucial), it should be seen as a Is bed rest an appropriate therapeutic
complex disease with physiological (“biological”), psycho- approach in back pain?
logical, and psychosocial infl uences (according to the bio- Bed rest is only appropriate for acute radiating pain
psychosocial model of chronic pain evolution). Th erefore, (sciatica), but it should not exceed 1–3 days to avoid
when local therapies alone fail to give long-term pain re- progressive inactivity and avoidance, which reinforces
lief, a major diagnostic and therapeutic workup including abnormal illness behaviors. For all nonspecifi c myo-
physical, psychosocial, and neuropsychological aspects fascial pain, inactivity would have deleterious physi-
(“multimodal therapy”) may be needed. ological eff ects, leading to shortened muscles and
If adequate therapy is delayed over several months other soft tissues, joint hypomobility, reduced muscle
with a trial of unimodal therapies, such as analgesics or strength, and bone demineralization. Th erefore, bed
injections only, long-term positive eff ects of multimodal rest should not be advised. Th e patient should be in-
therapeutic approaches become unlikely or very limited. structed to continue “normal daily activities” as much
as possible. Any bed rest recommendations would only
What are the diagnostic reinforce malcognitive and malconditioned behavior
strategies in back pain (“fear avoidance beliefs”), resulting in a viscous circle
lasting more than 3 weeks? of bed rest—increased fear of movement—increased
pain on movement because of muscular decondition-
Unrelenting pain at rest and the other “specifi c pain red ing—more bed rest. For these reasons, bed rest is defi -
fl ags” should generate suspicion for cancer or infec- nitely not recommended as a treatment for nonspecifi c
tion. Appropriate imaging is mandatory in these cases. back pain.