Back pain is one of the most common health complaints, affecting more than one in four adults every year, and a popular reason for physician visits. But most people recover from back pain whether they are treated medically or not, says Wolf Mehling, a professor of medicine at the University of California at San Francisco.
For people who do see a doctor, research shows that while the vast majority get better, a small percentage get worse. In a recent study, Mehling and his colleagues interviewed 521 people six months after they had seen doctors for acute back pain; 81 per cent of them were completely recovered or much improved, while 16 per cent were the same or slightly improved and 3 per cent were worse off.
The American College of Physicians guidelines for back pain generally recommend over-the-counter pain medication, rest and exercise for initial treatment for “nonspecific” back pain, which means pain that is not clearly linked to injury or disease. Yet many people go to the doctor for nonspecific back pain, where they are often given prescription pain relievers and/or are sent for expensive tests. (Of course, if you have severe pain and/or have been injured, you should go to the doctor immediately.)
A recent study categorised treatments offered in nearly 24,000 patient visits for back or neck pain over a 12-year period. (This sample did not include people with “red-flag” symptoms such as pain radiating down the leg, which can indicate a nerve problem.) Prescriptions for opiate pain medication increased, from 19 per cent in 1999-2000 to 29 per cent in 2009-2010; likewise, referrals to another physician increased from 7 per cent to 14 per cent, and CT or MRI scans increased from 7 per cent to 11 per cent.
These trends run counter to clinical practice guidelines for acute spine pain, such as those published by the American Pain Society and the American College of Physicians, the study says.
Getting an MRI scan or an X-ray is a reasonable step if back pain has persisted for six weeks or more, the guidelines say. Then, doctors are looking for such possible causes as a herniated disk or a bone spur.
But imaging can be misleading, Mehling says. In “25 per cent of people walking down the street with no pain,” doctors could find some pathology, he says, such as bulging or thinning disks.
Indeed, says Daniel Cherkin, a senior investigator at Seattle’s Group Health Research Institute, “in 85 per cent of people, it’s not possible to confidently identify a cause of back pain.”
With unclear cause, treatment options are murky. Yet many doctors turn to surgery. Twenty years ago, Cherkin documented that rates of back surgery in the United States were double those of many countries’ and five times those of the United Kingdom. Eight years ago, another group found dramatic regional differences in back surgery rates within the United States.
“As a spine surgeon, I try to avoid surgery,” says Jay Khanna, director of the Johns Hopkins Orthopedic and Spine Surgery practice for the Washington area. For chronic back pain, he recommends physical therapy to strengthen the muscle support for the spine as well as “activity modification”, which might mean avoiding bending over or lifting heavy things. If pain persists, he may recommend injecting steroids or nerve blocks directly into the back. Such injections provide temporary relief from pain — weeks to months for steroids — which might be enough time for natural healing or physical therapy improvements to take place.
Cherkin suggests that doctors and patients take a broader view of back pain to include not only physical causes but also psychological ones. Mehling says two frames of mind make it particularly likely that back pain will persist: “fear of moving — the belief that if you move, you’ll make things worse,” and catastrophising — worrying that you’ll be debilitated for life.
More and more researchers are studying how the emotional component of pain contributes to back problems. One study, for example, found that people with acute back pain had increased activity in sensory areas of the brain but that people with chronic back pain had increased activity in emotional areas of the brain, which suggests that doctors should find ways to address the emotional aspects of lingering back pain, not just the physical aspects. Evidence-based guidelines have been developed in Britain that address the psychological component of low back pain.
Here are a few tips to help mitigate back pain:
Over-the-counter pain medications such as acetaminophen and ibuprofen can help make you more comfortable, as can ice or heat.
Practice common sense, such as getting sufficient rest, stretching and, of course,avoiding positions that hurt or strain things further. But — unless you absolutely must — lying in bed is not a good idea. Moving is key. “I usually say, ‘Do some gentle exploring of your range of motion,’” Mehling says.
Alternative care, such as chiropractic, acupuncture, physical therapy, therapeutic massage or yoga, may also provide relief. In 2007, the American College of Physicians reviewed the evidence and found that these methods had some positive effects for back pain that lasted more than one month.
“Generally, patients who go to a massage therapist or a chiropractor are much happier with results of their treatments than those who go to their family doctor,” Mehling says.
–Washington Post
