Back pain is rarely life threatening; yet most patients are willing to take any reasonable measure to stop the torture.
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If you’re all tied up in knots because of a sore back, you might not take kindly to the view expressed by Dr. Richard Deyo that “back pain is part of living and being a human being.”
At least 80 percent of Americans suffer back pain at one time or another, but most are not ready to admit that it’s something to be endured. More than 250,000 each year are willing to undergo spinal fusion procedures in an effort to quiet the pain.
Dr. Deyo, a professor of medicine at the University of Washington, authored an article in the New England Journal of Medicine [February, 2004] questioning the effectiveness of spinal fusion surgery for the majority of back pain patients.
Based on Deyo’s study and other evidence, most doctors agree that surgery should be reserved for only the most recalcitrant cases and that self care is nearly always the best initial treatment. More controversial is the view put forth by Nortin M. Hadler, M.D. in an editorial in the Journal of the American Medical Association [June 4, 2003]: “Today, individuals with regional back pain might fare less poorly by managing as best they can on their own, perhaps with some lay advice, than if they choose to become primary patients.”
The “regional back pain” Dr. Hadler refers to is precisely what most patients have, and 90 percent of these cases will resolve on their own with little or no treatment. Rarely is back pain life threatening or caused by serious disease. If you’re otherwise healthy and haven’t suffered serious trauma to the back, there’s usually no harm in waiting.
Stop doing whatever aggravates the pain, take over-the-counter pain relievers at the recommended dose and use ice and heat packs to ease the pain. (Generally, ice is recommended for the first two or three days after which time heat may be more likely to provide comfort.) Bed rest, once recommended for back pain, is now known to be the worst course of action, leading to a downward spiral of pain, soreness and disability. Whatever else you do, it’s important to remain as active as possible.
Crawling to the Clinic
Self care is easy enough to say if you’re not suffering intense pain. Most patients who seek medical help do so because their pain is virtually unbearable; one doctor recalled a 240-pound truck driver who crawled into his office on his hands and knees, crying.
When you’ve run out of patience, the logical place to start is your family physician or internist. She can give you a complete physical examination, check your posture and gait, perhaps take some x-rays and prescribe more powerful pain medications. She may also order laboratory tests to rule out a malignancy or infection.
While you may be convinced that something serious must be causing your pain, studies show that sophisticated tests and specialist assessments are in most cases not worth the expense. After one year, subjects having conventional x-rays were as likely to get better as those undergoing magnetic resonance imaging (MRI) scans–even though subjects having MRI scans were more likely to undergo surgery and have specialist consultations.
In 90% of cases, back pain will resolve on its own with little or no treatment. Bed rest is now known to be the worst course of action.
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Causes of back pain include strains, sprains, muscle spasms, structural problems such as curvature of the spine and degenerative changes in the bones and discs of the spinal column. While the diagnosis of “ruptured disc” may by itself sound bad, studies have found no correlation between disc problems–or other anatomical defects–and the severity or prevalence of back pain. One study of healthy subjects found that about 65 percent had abnormal discs without pain.
Whatever the cause of the pain or its location, treatment is likely to include anti-inflammatory medications, education about back care and a personalized exercise program that includes aerobic activity, strength training and stretching. If there’s no improvement after a month or so, consultations may be sought with a specialist such as a physiatrist, orthopedist, neurologist, neurosurgeon or rheumatologist.
When patients are allowed to choose their back treatment options, they are usually pleased with the results.
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An increasing number of Americans have been turning to what are known as “complementary” or “alternative” therapies such as massage, chiropractic manipulation and acupuncture.
Chiropractors now treat at least 30 million back pain patients each year. Guidelines issued in the mid-1990s by the Agency for Health Care Policy and Research concluded that spinal manipulation is a “recommendable method of symptom control” and “can be helpful for patients with acute low back problems without radiculopathy (nerve irritation related to disc damage) when used within the first month of symptoms.”
One recent study found that chiropractic spinal manipulation was better than sham treatments, but neither more nor less effective than standard non-surgical therapies.
Therapeutic massage was found to be more effective than acupuncture or placebo in treating short-term pain. Acupuncture was effective but not necessarily more effective than sham acupuncture.
Some research indicates that expectations are important: when patients are allowed to choose their back pain treatment options, they are usually pleased with the results. According to a study funded by the Agency for Health Research and Quality, patients are about 30 percent more likely to be satisfied with the advice and treatment they get from chiropractors, compared to what they get from physicians.
One often overlooked component of back pain is stress. According to Dr. John Sarno, author of Healing Back Pain, most incidents of back pain can be traced to bottled up emotions. According to Dr. Sarno, “Pain is created by the brain to make sure the rage doesn’t come out.” The answer for Dr. Sarno’s patients is talk therapy and meditation.
A Canadian study published in Pain [January, 2004] found a strong association between back pain and depression. Depressed persons were more likely to get back pain and back pain patients were more likely to become depressed.
Probably the most prevalent view today is that no single approach to back treatment offers all the answers. A National Institutes of Health pilot program now underway is involving a diverse group of 25 specialists in an effort to determine the feasibility and cost-effectiveness of a multi-disciplinary approach. Each patient will meet first with one physician and one alternative medicine provider who will then consult other team members to draw up a treatment plan.
In most cases, the goal is not to fix the back, which in time will take care of itself, but to stop the pain that is making life unbearable and allow the patient to get back into action.
REFERENCES:
“Back Pain: The Evidence Points to ‘Heal Thyself’,” Johns Hopkins Medical Letter, July, 2004.
Daniel DeNoon, “Lower Back Pain: Hurt Doesn’t Mean Harm,” WebMD, January 20, 2004.
“Help for Back Pain Sufferers,” Community Pharmacy, May 11, 2004.
S. Laurance Johnston, “Chiropractic Healing, Parts 1 and 2, Paraplegia News, October and November, 2003.
Claudia Kalb, “The Great Back Pain Debate,” Newsweek International, May 10, 2004.
Timothy F. Kirn, “Prevent, Relieve Lower Back Pain: Data Support Benefits of Core Strengthening Exercises,” OB GYN News, June 1, 2004.
“A Lingering and Uncomfortable Question: Should Patients with Back Pain Avoid Doctors?” The Back Letter, December, 2003.
“Low Back Pain ‘All in the Mind’,” Pulse, May 31, 2004.
Diana Mahoney, “Nonsurgical Care Relieves Back Pain: Behavioral Intervention, Internal Medicine News, September 15, 2003.
“Massage Better for Back Pain than Other Alternative Therapies,” The Journal of Musculoskeletal Medicine, January, 2004.
Peter Moore, “Chiro Practicalities,” Men’s Health, January-February, 2004.
James Rainville, “Exercise Tops Options for Treatment of Chronic Back Pain,” Biomechanics, July 1, 2003.
Richard Sadovsky, “Massage and Manipulation Can Help Persistent Back Pain,” American Family Physician, February 1, 2004.
“Self-Management Improves Physical Function for Patients with Acute Low Back Pain,” Biotech Week, December 17, 2003.
“Spinal Manipulation Effective for Low Back Pain,” JAAPA–Journal of the American Academy of Physicians Assistants, December, 2003.
“A Spinal Research Pioneer Comments on the Changing Paradigm of Modern Back Care,” The Back Letter, December, 2003.
Michele G. Sullivan, “Address Psychosocial Aspects of Back Pain: Preventing Disability,” Internal Medicine News, September 15, 2003.
Richard Trubo, “Fighting Back When Your Back Aches,” WebMD, July 19, 2004.
Nancy Walsh, “Chiropractic for Back Pain,” Family Practice News, September 1, 2003.
Mark Whitaker, “The Editor’s Desk,” Newsweek, April 26, 2004.
