By: Staff Reports | Gwinnett Citizen
Ruben Diaz MD

Conservative Spine & Joint Center
By Ruben Diaz, M.D.
Conservative Spine & Joint Center

Back Pain Facts FAQ's and red flags

•Approximately 80% of all adults will have lower back pain at some point in their lives
•The most common cause of chronic pain is poorly treated acute pain
•There are multiple causes for back pain, and each one is treated differently.
•Approximately 95% of all back problems do NOT require surgery
•From 2004 to 2010, medical emergencies related to the nonmedical use of pharmaceuticals increased 119%.  Contributing to this rise was the 149% increased involving narcotic pain relievers.
•4.4 million Adults > 50 years old are in need of a substance abuse treatment.

What to expect as a patient when you have back pain?
-To be seen as soon as possible
-To be seen by a physician with training not just in pain, but also in musculoskeletal problems and their rehabilitation.  
-To have the appropriate workup and diagnosis provided as soon as possible, so your targeted treatments can start as soon as possible (Sometimes dependent on approval by your insurance).
-To have the physician provide information and education regarding your condition or conditions, and to discuss the appropriate treatment plan.

Are all types of pain the same?
NO. There are different types of pain, and each one is treated differently. For example:

Nociceptive pain is the typical pain you get from an injury to muscles, ligaments, bones. Usually a deep aching, throbbing pain.

Neuropathic pain is the pain you get from injury or irritation to a nerve. Usually can feel like pins, needles, tingling, burning, electrical shooting pain.

Visceral pain is the pain you get from distention, inflammation and/or decrease blood supply of the organs. Usually more diffuse pain, squeezing, crampy, dull discomfort usually can be associated with nausea and vomiting.

Are all back injections Epidural injections?
NO. There are multiple procedures for pain relief, and epidural injections are only one of many options. The procedure, level or levels done, approach/technique, medication concentration may be different depending on the specific pain generator/target to be injected.

Are opiates the only medications for pain?
NO. There are multiple medications used for pain relief which are not opiate medications. For example anti-inflammatory medications, muscle relaxants, medications used for anxiety and depression have been found to help with certain types of pain. Medications for seizures have been found to help for pain (especially nerve pain), Botox (Headaches, spasticity, dystonia etc.), DMARD’s (medications for Rheumatological problems), anesthetics, medications to control heart rate have been used for headache management (Beta blockers), medications for blood pressure control (Calcium channel blockers) have been used for different pain problems etc. Depending on the problem your physician should be able to prescribe the appropriate medications.

Does opiate medications have any side effects?
All medications can give you side effects. Opiate medications can cause: Sedation, respiratory depression, nausea, vomiting, urinary retention, mental clouding, itching, biliary spasms, affect your immune system, affect several hormone production including testosterone, insomnia, Sleep apnea, some can affect your heart (Q-T interval), some can increase the risk of seizures, and cause opioid hyperalgesia among others.

Why is therapy important?
In many cases I divide therapy in three areas. The initial stage will help to promote healing and decrease pain. The second will allow the patient to gain strength and flexibility in areas that had deficiencies leading to the problem. The third includes patient education including: Posture, biomechanics, ergonomics, weight reduction, home program.  Teach the patient what he/she can do and can’t do. The things that can be done, how to do it properly. How to take care of the affected area to avoid the same problems in the future.  

Red Flags
1-Physical Therapy-As part of the initial treatments available for back pain is Physical therapy. 
-Targeted Physical therapy done properly can be very helpful to patients.
-Careful when your Physician orders for therapy will only read: 

Diagnosis: Back Pain please Evaluate and treat. (Red Flag)
First- Back pain is not a diagnosis, it is just describing the area with the problem. There are multiple causes for back pain, and the specific cause (Pain generator) should be included in the therapy prescription.

The Prescription for therapy should be almost like a medication prescription.

Therapy prescription should include:
*Specific Diagnosis 
*The Specific therapy program including Modalities, Therapy Program, exercises, etc. in the order it should be provided to the patient.

Insurances will approve only a limited amount of therapies. If those are incorrectly done or you get a “cookie cutter” program, then you may lose the chance to get something very helpful. 

Precautions are very important. You should not get the same therapy if you have different back pain diagnosis/pain generators, for example: Compression fracture vs Failed Back Syndrome vs facet arthropathy are all treated differently. If the prescribing physician does not recognize that each of these problems will have specific precautions in therapy, then your condition may worsen. (First rule of medicine-DO NO HARM).

2-Targeted therapies-if you are getting therapy at the same time with multiple other patients (doing the same program) under the supervision of one therapist, then by definition alone, you are not getting a specific targeted program individualized to your problem.

3-Procedures- Pain procedures are multiple, and when properly done can significantly reduce pain which will allow the patient to be more active, improve quality of life, and allow the patient to depend less in medications for pain control. 

Red Flag-Sometimes you can be scheduled for a series of 3 procedures with NO follow up evaluations in between. As a patient and as a Physician I would like to know that the first procedure helped, and if so how much, then further determinations on whether to do the other blocks can be made. If the first one did not helped then why have 2 more. (These procedures can be expensive, and also may have risks)

More and more you will see Insurance companies asking to do evaluations after a procedure to see if it was truly helpful. 

In my experience if you have the right pain generator/target for your procedure you should always get at least >75% relief with your first injection. (Usually closer to 100% unless there is a secondary problem that will need to be addressed at a later date).

If you have a procedure with no relief then either the pain generator was wrongly identified or the procedure itself was poorly done.

4-Pain medications

Red Flag: A Physician who only wants to prescribe opiate medications.

There are multiple pain medications.  From anti-inflammatory medications, muscle relaxants, Medications specific for nerve pain, medications specific for rheumatological conditions, and opiate medications.

If your physician is able to identify the right pain generator/generators then a precise medication plan can be established.

In most conditions the Physician should try to maximize the use of non-opiate medications to control your pain. 

I have been practicing for over 20 years, and every few years there seems to be a cycle in terms of use of opiate medications.  Sometimes not enough use, and sometimes too much use.  At this point in time we are in a cycle in which there is an increase in the use of opiate medications.

Patients need to understand that anything that you put in your system will have positive and negative consequences.  Opiate medications certainly have their role, but have to be used carefully due to the negative side effects.  Recent research has shown that the opiate medication efficacy is fair for the use in the short term, but only limited in chronic use (>3 months).

In some musculoskeletal conditions it is used during the acute phase, and once the condition is stabilized, then the medication should be weaned off.

Opiate medications can cause dependency and in some cases addiction. Opiates have significant side effects including among others: Sedation, respiratory depression, nausea, vomiting, urinary retention, mental clouding, itching, biliary spasms, affect your immune system, affect several hormone production including testosterone and insomnia.

More recent studies have shown that approximately 75% of the patients on opiates can develop sleep apnea.  Affecting sleep patterns can affect musculoskeletal conditions like myofascial pain and fibromyalgia.

Other studies have shown something called Opioid hyperalgesia.  In which Opiate medications may decrease the pain threshold in a patient, meaning that patients may develop pain sooner with less activity or activity that did not cause pain in the past.

The information above was provided by Ruben Diaz M.D. who is an Interventional Physiatrist at the Conservative Spine and Joint Center in Lawrenceville. Dr. Diaz has over 20 years of experience. He is Board Certified in Physical Medicine and Rehabilitation Specialty, and Pain Medicine Subspecialty. 

Dr. Diaz has done teaching to 3 different Medical Schools including 7 years for the Emory PM&R Department, where he won Teacher of the Year award. Dr. Diaz provides an Internship program during the summer to GSMST students.

Dr. Diaz clinic goals:
Decrease pain
Decrease need for strong chronic pain medications
Increase function
Increase quality of life
Avoid unnecessary surgeries
Education of the patients 

Conservative Spine & Joint Center
O: (770)601-4340 x2
Fax: (678)442-1324