Monday, February 20, 2017

Pain: Avoiding MRI's and Narcotics

There is concern that too many MRI's are being ordered to evaluate pain and too many narcotics are being used to 'treat' pain. These concerns are nicely illustrated in a recent New York Times article:

Lower Back-Ache? Be Active and Wait it Out, New Guidelines Say.

While back pain is not shoulder pain, back and shoulder pain are common reasons for patients to come to see a doctor. The guidelines for managing back pain are becoming increasingly safe, conservative, and cost-effective; see this link.

"The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief."

"In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.

“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”

Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmacological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin.

Scans, like an M.R.I., for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalities that actually are not related to the pain."

Comment: While the shoulder is not the back and every patient is an individual, we agree that two of the biggest problems encountered in caring for individuals with shoulder problems are (1) an MRI ordered by a doctor without a specific question in mind that reveals 'findings' that are not related to the patient's symptoms and (2) patients who have been given narcotic pain medications by a doctor to which they have become habituated and from which they are obtaining less and less relief.

For patients without an obvious injury, we often begin by obtaining simple x-rays (as shown in this link) and starting gentle exercises (as shown in this link).