Physical findings in patients with chronic intractable benign pain of the neck and/or back

Abstract

Chronic intractable benign pain (CIBP) is defined as non-neoplastic pain of greater than 6 months duration without objective physical findings and known nociceptive peripheral input. To test the CIBP concept, 283 consecutive chronic pain patients were examined independently by a neurosurgeon and physiatrist and only congruent physical findings were coded. Because they did not fit the CIBP definition, patients with the following primary treatment diagnoses were eliminated: degenerative disease of the spine and spinal stenosis; degenerative disease of the hips; radiculopathy; malignancy; deafferentation pain; and miscellaneous. Eliminated, also, were patients with any one finding indicative of a root compression syndrome, leaving 90 low back and 34 neck patients. These patients had abnormal physical findings in 7 categories: tender points/trigger points; decreased ranges of motion in back or neck; non-anatomical sensory loss; rigid musculature; decreased range of hip motion; gait disturbance; and miscellaneous non-neurologic signs. Low back CIBP patients had the following distribution among the 7 categories: 0% had findings of all 7; 1.1% had 6; 13.3% had 5; 24.4% had 4; 25.6% had 3; 26.7% had 2; 8.9% had 1; and 0% had none. Neck CIBP patients, in which only the first 4 categories of physical findings were applicable had the following distribution: 2.9% had 4; 41.2% had 3; 35.3% had 2; 20.6% had 1; and 0% had none. It was concluded that CIBP patients do have abnormal physical findings indicative of musculoskeletal disease: possibly fibrositis and/or specific myofascial syndromes, as sources of peripheral nociception. These findings question the validity of the CIBP concept and point to the need for a careful, all-inclusive physical examination as a basic initial requirement in the classification of chronic pain patients.

A Structured Evidence-Based Review on the Meaning of Nonorganic Physical Signs: Waddell Signs

“…Finally, it is well known that trigger points in myofascial pain syndrome (MFPS) have been reported to refer not only pain/tenderness, but also numbness [80] and do not follow dermatomal referral patterns [81]. Indeed, nondermatomal sensory loss and nondermatomal deep tenderness are frequently found in MFPS [82,99]. Therefore, nondermatomal sensory abnormalities are consistent with referred MFPS phenomena.…”

Misdiagnosis of chronic pain as hysteria and malingering

“…For instance, myofascial pain in the area of the lumbar, thoracic, and cervical spine may be variously diagnosed as mechanical back pain, facet joint pain, root irritation, cervical-lumbar sprain, whiplash, thoracic outlet syndrome, and nonspecific low back pain. Notwithstanding these diagnostic difficulties [11], it is likely that these soft tissue or musculoskeletal pain conditions represent the majority of chronic pain disorders seen in rehabilitation settings and pain clinics [12].…”

A Comprehensive Protocol to Diagnose and Treat Pain of Muscular Origin May Successfully and Reliably Decrease or Eliminate Pain in a Chronic Pain Population

“…It is estimated that 70–85% [21,47] of patients with low back pain have nonspecific low back pain. We suggest that a large percentage of these patients with not only low back pain, but upper back and shoulder pain as well, have a muscular component to their pain [28,29,48]. Although we only specifically address those patients with MPAI as a cause of pain, many of the patients had pain also from weakness stiffness, and tension, which we did not specifically analyze.…”