Assessing the Prognosis of Back Pain
This chart is applied for assessing the prognosis of musculoskeletal pain. For the purposes of this discussion, I will use the example of lower back pain. It gives the clinician skills to predict the outcomes and recommended duration of treatment.
Category A: Acute Pain, Getting Better
“Celebrate- victory is near!”
This is the most positive prognosis. This category most commonly indicates musculoskeletal strains/ sprains with sudden onset.
Acupuncture treatments are typically indicated 1 – 3 times per week for two weeks. Usually the problem is resolved within this time span.
Regardless of therapeutic modality, the patient’s condition will usually improve within about a month’s time. Acupuncture can accelerate the recovery and often hastens a dramatic resolution of the pain or injury.
Category B: Chronic Pain, Getting Better
“Nearing the end of a painful time.”
This can cautiously be considered a positive prognosis. In the case of back pain, this generally refers to the end stage of a disc related problem. Uncomplicated disc problems usually resolve themselves spontaneously within six months, and the patient can resume normal activities.
Reducing inflammation to the impinged nerve, and local tissue repair makes for a longer-term acupuncture therapy, usually 10 -15 treatments over two months.
Category C: Acute Pain, Getting Worse
“What are we dealing with here?”
A differential diagnosis is essential for this category. One should rule-out between a sprain /strain, disc problem, tumor, arthritis, or another condition. A thorough health history and physical examination leads to a diagnostic impression, which can if necessary, be further confirmed by an MRI or X-Ray. The diagnosis will determine the therapeutic plan. In the case of lumbar pain, if it is a sprain/strain see category A. If it is a disc problem, see category B.
Category D: Chronic Pain, Getting Worse
“We’re in for the long-haul.”
For back pain patients, this generally applies to disc problems with multiple episodes, spinal stenosis, patients that have had back surgery, arthritis, spondylosis, and other serious conditions. This is the poorest of prognoses, and is difficult to treat. This will require long-term therapy, over 20 treatments for up to six months. Some patients may achieve only minimal, temporary results, or relapse after improvement.
Further Discussion on Category D:
Category D is the most difficult to treat. Patients have had their back pain for six months or more (chronic) and their pain is getting worse (or has stabilized without recent improvement). These patients have often tried various therapeutic modalities with minimal success, if any: Cortisol and/or trigger point injections, surgeries such as discectomy, fusions, or rod implants, and in some cases, the back surgery may have failed. Patients may experience “drop foot,” radiating pain, and numbness down the leg (sciatica). They may have a recurrent herniated disc, spinal stenosis, spondylopathy, severe injury, or a variety of other spinal diseases. These patients suffer an excruciating amount of constant pain, with relief perhaps only from narcotic medications. Often these patients come to an acupuncture clinic as a “last resort,” after all other interventions have failed.
For these patients acupuncture has its limitations, but can still be of great benefit.
One must manage the patient’s expectations in a realistic and ethical manner. There is not a failure of treatment, but only communication. Patients will have more confidence in treatment if the clinician can clearly communicate the objectives of treatment, and honestly discuss expected outcomes. If there is any pain relief after the first treatment, it may be short-term, perhaps only as long as it takes for the patient to return home. If the pain returns, the patient may become discouraged about the benefits of acupuncture.
It first must be communicated that the Category D condition is difficult and complicated, and acupuncture may or may not be effective. However, it is still worthwhile to give acupuncture a chance. If the condition shows a shift (even a minor improvement) within the first 4-8 treatments, the prognosis is good that acupuncture will be of long-term benefit (although it may not be curative).
It is important to illustrate that the effects of acupuncture are cumulative, and each treatment builds upon the foundation previously established by past sessions. It is also imperative to stress the benefit of regular treatment, so that the patient does not regress, and prolong the treatment course.
If progress is slow, it is important to help the patient identify particular milestones in their recovery. Help the patient to see the light at the end of the tunnel. It is important to note even small improvements in pain, range of motion and/or function. If these benefits are transient, and the pain returns, they are still positive achievements. If the patient is able to maintain an optimistic (yet realistic) state of mind during treatment, this has profound implications on prognosis for chronic conditions. No matter the diagnosis or condition being treated, optimistic patients respond better than pessimistic patients.
If pain relief or physical function has improved, even for a short period of time, the goal of the next treatment should be to try to double the positive result. For example, if the patient was able to walk 5 or 10 minutes with less pain, attempt to make it 10 or 20 minutes within the next few treatments. Perhaps the patient will be able to sleep more comfortably, with less interruption from pain.
Also crucial for the Category D patient is a modification of lifestyle, and implementation of a carefully designed Home Exercise Program. It is critical to teach proper posture and body mechanics. The patient must have optimized ergonomics both at home, and in the workplace. Proper posture and ergonomics will facilitate the effects of acupuncture treatments, allowing for longer-lasting relief. The Home Exercise Program should focus initially on increasing flexibility (stretching: especially hamstrings, psoas, and spine flexibility), and then on improving strength (particularly core abdominal muscles).
Also take note of posture in the cervical spine (neck) and shoulders, and correct problems here as well. Misalignment in one area of the body can have a cascading effect, causing pain in other areas. It is quite common for low back pain patients to have shoulders that are rounded forward, and forward protrusion of the neck. Rounded shoulders can be corrected with stretching of the pectoralis muscles in the chest, and strengthening the rhomboid muscles between the scapulae. Neck protrusion can be corrected by strengthening the deep flexor muscles of the neck.
The Category D patient is going to need intensive therapy for up to 6 months. The pain took a long time to develop, and it usually takes a long time to resolve. The expectations for immediate, significant relief should be minimized and explained at the initial consultation. Emphasize the improvements and gains made, and try to double them in subsequent treatments.
This article is re-posted (with updated content) with permission from Dr. Evan Mahoney, L.Ac., and Dr. Hyungsuk Choi, L.Ac.
© 2014 Nathan Anderson, L.Ac.