Melbourne Mid-Year COCA Seminar Review
by Dr Liz Baker BAppSc(Chiro)

In a beautifully referenced, considered presentation, Prof Rob Helme PhD discussed pain in the elderly. He opened with the IASP 1986 definition of pain, commenting that unpleasantness is an aspect seldom measured, and gave an instrument by Gracely for doing so.

Prof Helme demonstrated that ageing is defined as a loss of functional reserve and we have most reserve in middle life, but the greatest variability of reserve across the population comes in later life. This, he argues is primarily is due to disuse, not age per se, and he went on to discuss the significance of biological ageing, disease and environmental effects on this variability.

He then presented evidence that 50% of seniors have chronic pain. Reviews suggest the aged cope with minor surgery better than the young, but don’t cope as well with chronic pain. Experimentally, ageing is associated with increased secondary hyperalgesia. As the parameters of pain are different in elderly, some commonly used tools may not be valid. The Short Form McGill Pain Questionnaire is valid in this group.

Studies were discussed demonstrating a higher pain threshold in the elderly and a poorer ability to turn on the descending inhibitory pathways.

Prof Helme discussed pain clinic evaluation of the elderly, and considerations in their management. Treatment goals may vary with age, maintenance of mobility is often preferred over pain relief. In managing chronic pain, older cohorts have less experience with psychological approaches, but if its “done right” they benefit. Prof Helme also observed that physical and cognitive impairments may be obscured by the wonderful social graces of the elderly!

In questions, Prof Helme observed that we have “no therapies that are much good for pain” and commented that pain is so important to the survival of the animal that there are many fallbacks for getting pain through. It is unlikely, he argued, that we’ll be able to block them all, therefore function is the desired outcome of intervention. In manual therapy he feels the emphasis should be on teaching people to do things for themselves, or we risk prolonging the condition. He referred again to the limited reserve of this cohort, and the resultant need to be careful and gentle doing anything to them. In the young he said, 2 weeks of deconditioning takes 6 weeks to recover. In the elderly the recovery may take months.

Sociologist Ian Coulter PhD danced us through seven years experience of developing evidence-based reports for governments on the efficacy of complementary and alternative medicine (CAM), and the outcomes of those reports.

The program Coulter works in was begun in 1997 by the USA’s Agency for Health Care Policy and Research - (now Agency for Health Research Quality). 11 centres across the USA and one in Canada were established in existing institutions, comprising “lots of expertise and talent,” and more funding than Cochrane could dream of. With methods experts in epidemiology, health services research, bio-statistics economics, decision analysis, cost effectiveness analysis and meta analysis, the team was charged to develop rigorous methods of review, to be applied to mainstream medicine and CAM. They were to develop systematic reviews of the benefits, harms and costs of interventions, called Evidence Reports. They were to assist third parties in developing practice guidelines or medical review criteria and finally they were to research the science of systematic review or guideline development. This latter included observation studies of expert panels - how much they actually considered the evidence in developing guidelines and how much their clinical acumen overrode the research. Coulter was working at RAND, part of the Southern California EBP centre.

The methodology used was discussed, with Coulter pointing out that the literature searches are exhaustive, covering even the Grey Literature, chasing the unpublished negative results and the non-mainstream databases. He lamented that Cochrane only review the English language literature (what of Manuel Medizin!) and that their review of manipulation didn’t review Chirolars.

The first meta-analysis on CAM was RAND’s “The Appropriateness of Spinal Manipulation for Low Back Pain”. Going in, the researchers were ambivalent about CAM and chiropractic. The literature search however found 29 RCT’s, equal to or more than for any medical procedure studied. Usually they’d try for 15 trials, 7-8 if they were good trials. 29 was exceptional. By the end, even the multidisciplinary panel with its neurologists and neurosurgeons was saying we should manipulate acute low back pain. The result for chronic low back pain was equivocal due to insufficient data.

RAND’s “The Appropriateness of Manipulation and Mobilisation of the Cervical Spine” found the RCT’s too varied for meta-analysis, and concluded a short term benefit for patients with neck pain and tension headaches. Again paucity of evidence precluded other conclusions. RAND put the complication rate at 6.9/10 million manipulations.

With efficacy established, the next task was to decide what percentage of the intervention’s use is appropriate. In most medical interventions about 30% of the use is found inappropriate. A field study of the appropriateness of manipulation for low back pain found that 29% got inappropriate care - they didn’t meet the criteria but they got adjusted, 36% however were judged appropriate but did not receive manipulation. The press latched on to the 29% inappropriate - while ignoring the 32% of carotid endarterectomies that were found inappropriate - and didn’t consider the massive under-servicing.

These 2 studies were significant in that they showed that CAM could be researched with standard methods, and that lead to funding for further research.

Coulter then waltzed us through the reports “Mind Body Interventions for Gastrointestinal Conditions”, “Ayurvedic Interventions in Diabetes Mellitus”, and a “Best Case Series for Cancer”. Evidence Reports on “The Effect of the Antioxidants Vitamin C, Vitamin E and Co-Enzyme Q-10 on the Prevention and Treatment of Cancer,” and of cardiovascular disease, found not very good evidence for either.

Coulter concluded that the projects had showed that such research is difficult, and expensive, particularly as it is international, but possible. The common problems encountered were language, power, design, and reductionism. He argued that if you use a reductionist approach you have not studied chiropractic in toto. To the age old stumbling block of heterogeneity, he said gloriously, “No two patients are the same but that’s just a methodological problem.”

The evening concluded with the ever -delightful Dr Stan Innes, chiropractor and psychologist, discussing psychological factors in persistent pain.

In a beautifully measured presentation, Dr Innes opened with Gordon Waddell’s 1993 quote, “Fear of pain is more disabling than pain itself.” and reviewed the physical and psychological vicious circles arising from back pain. He then elegantly compared the features and management of a spider phobia with the fear of pain. The cardinal features, avoidance behaviour, psychophysiological reactivity and worry were familiar enough. What caught me by surprise was the hyper vigilance. Spider phobics are quicker to spot a spider in a scene than normals and on reflection, my pain phobic patients are certainly quicker to spot pain.

Dr Innes went on to review the Cardinal Yellow Flags, the warning signs of psychological factors involved in chronic pain. He covered those relating to work, the beliefs and behaviours, and the affective aspects of the state - which interestingly included a socially punitive spouse/partner. He introduced us to the Yellow Flags Scoring Questionnaire, suggesting that one should start seeking yellow flags at one month pain duration.

He then defined depression and listed its features, and introduced us to the Modified Zung Index, and the Modified Somatic Perceptions Questionnaire, both suitable for routine use in practice. He suggested that they be used if you are hearing the yellow flags and the patient is not responding to treatment. There is caution to be exercised in cutting down your involvement to avoid the patient feeling abandoned.

The core practical advice was, look early for yellow flags. If you see depression, get a psychologist on board. If you are not happy with the progress 4-6 weeks later, a review is warranted, and a multidisciplinary pain management centre may be of great assistance. Such centres can be expected to decrease medication use by a factor of 3, decrease treatment visits by a factor of 8, double the likelihood of RTW and increase physical functioning by a factor of 4.

And if you’ve never seen Dr Homer’s Miracle Spinocylinder in action it serves you right for not attending!