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Pathology and chronic pain

An article ("With Costs Rising, Treating Back Pain Often Seems Futile ") in the 2/9/04 New York Times notes:

A variety of studies have suggested that in 85 percent of cases it is impossible to say why a person's back hurts, said Dr. Richard Deyo, a professor of medicine and health services at the University of Washington. And most of the time, the pain goes away with or without medical treatment.

"Nearly everyone gets better, nearly everyone improves," said Dr. Deyo, citing evidence from large epidemiological studies. But he cautioned, "Getting better doesn't necessarily mean pain-free"...

In a study published last year in The Journal of the American Medical Association, Dr. Deyo and his colleagues randomly assigned 380 patients with back pain to X-rays or MRIs. X-rays can reveal tumors or fractures but not abnormal disks.

Half the M.R.I. patients had disk abnormalities, and the imaging patients, as a group, ended up with more intensive treatment — more doctor visits, physical therapy, acupuncture and chiropractic manipulations as well as more surgery. And while they were happier with their care, they fared no better than the X-ray patients. Within a few months, most patients in each group were feeling better and were back at work.

Why do the great majority of people with chronic pain have no clear-cut physical cause? (In many of the remaining cases, the cause is obvious. Only rarely does a straightforward physical cause of chronic pain remain undiscovered.)

Western medicine is based on the notion of "pathology," which means an abnormality in the body structure you can see on physical examination, x-ray, biopsy, MRI scan, or lab test. If you break a leg, the fracture is visible on x-ray. If you have pneumonia, you can see the infection within the lung on x-ray, biopsy, and any number of scans. Tumors are very visible lumps and bumps that shouldn't be there. Arthritis causes obvious inflammation, swelling, fluid, and joint deformities.

Physicians treat acute pain as a critical sign something is wrong in your body. If you came to my office with severe abdominal pain you never had before, I am trained to refuse to give you pain medications until we figure out what is wrong. People have died when given pain-reliving medications before a diagnosis was made. In this instance, the pain is a critical sign we must find the underlying pathology, or your life may be at risk.

But what is the pathology of a whiplash injury to the neck caused by an automobile accident (sprain, no broken bones)? Sure, immediately after the accident, one could find torn fibers in the neck muscles on a biopsy, but these heal within a few weeks. Why is it common to ache in the neck for months following the injury? There isn't any visible abnormality. Similarly, no one could see anything wrong with your muscles in the aching following a workout. Most muscle pains are the same: pain without a visible physical abnormality.

Despite many physicians' insistence that they only treat pathology, it is well known that many of the illnesses we treat show no visible abnormality anywhere in the body. This list includes early diabetes and hypertension, migraines and other headaches, depression and most other psychiatric illnesses, and especially fibromyalgia.


Last updated Sat, Oct 3, 2009

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©2011, James Gagné, MD