Pain in the Back

Most of the 56 million Americans who suffer from chronic low back pain are told to just take acetaminophen. The problem? It does little to relieve their discomfort. A recent study published in the British Medical Journal bears this out: Researchers concluded that Tylenol and other products containing acetaminophen were no more effective than a placebo for more than 1,600 people suffering from acute lower back pain. Prescription painkillers can provide relief in the short term, but because of their serious side effects, doctors are more and more reluctant to prescribe them. But the good news is that newer, drug-free treatments are gaining traction.

Back pain usually starts with muscle spasms — debilitating pain for short periods of time — typically triggered not by traumatic events but by mild tweaks.

“More than 70% of all adults experience disabling back pain at some point. It’s the most common cause of job-related disability and the reason behind most missed workdays,” says Rowland Hazard, MD, director of the Functional Restoration Program at Dartmouth-Hitchcock Medical Center in New Hampshire.

More than a quarter of adults — a figure Dr. Hazard puts at 30% — reported experiencing low back pain during the past 3 months.

Once back pain episodes become more frequent and intense, doctors might refer patients to spinal and orthopedic surgeons or order an MRI or other form of  imaging. They might learn that their particular brand of pain is the result of spondylitis (a type of arthritis that affects the spine), spinal stenosis (narrowing of the spaces between the bones of the spine, which can create pressure on the spinal cord and nerves), arthritis or degenerative disc disease.

Acute back pain tends to resolve itself after several weeks, but for people with chronic pain, it keeps recurring — and might, in fact, never go away.

Why Back Pain Diagnoses Are Evolving

Although it’s a remarkably common health issue, back pain is tricky to treat. Even with the sophisticated imaging tools at a doctor’s disposal, such as Magnetic Resonance Imaging (MRIs), often there’s no clear anatomical diagnosis.

‘We’re spending billions of dollars every year on treatment, MRIs, opioids and surgeries for people with back pain,’ Dr. Hazard says. ‘At the same time, there’s a disconnect. People are not feeling better.’

“A lot of images have false positives. Things will show up that are age-related but are not what’s causing the person’s trauma,” says Dr. Hazard. “Confusion and frustration arises from the difficulty of being able to make a specific diagnosis.”

And the rate of disability claims due to back pain are growing despite how much money we throw at the problem.
Back Pain and Disability
To improve treatment outcomes, doctors are beginning to shift their approaches to back pain. It’s no longer seen as a symptom, but a disease in and of itself. The spine is complex, and the pain can have a clear cause, such as a pinched nerve or herniated disc.

But it can also be a symptom of other medical conditions going on with the patient. Obesity and sedentary lifestyles, for example, also can set the stage for low back pain.

“In the last 5 years or so, a tidal wave of research demonstrates that sedentariness is substantially more impactful than previously thought,” says Stephen West, BS, RMT, a massage therapist based in Boulder, Colorado. “And the effects of sitting for 8 hours a day, on average, are not overcome merely by working out for 1 to 2 hours a day.”

 

Commonly Prescribed Medications – and Their Side Effects

Medication can be useful for short periods, but each subset has many deleterious side effects, especially for long-term use. Prescribing pain meds for back pain has become increasingly controversial and is done with greater reluctance than in previous decades.

A wide range of medications, from over-the-counter (OTC) to prescription, is used to treat low back pain. Many drugs are unsafe during pregnancy, interact with other medications poorly and lead to serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. The following are the 5 main types of medications used for low back pain:

Nonsteroidal Anti-Iinflammatory Drugs (NSAIDs)

This class of drugs relieves pain and inflammation and includes OTC formulations such as ibuprofen, ketoprofen and naproxen sodium as well as COX-2 inhibitors, available only by prescription. New studies contraindicate the long-term use of NSAIDs because of risks of stomach irritation, ulcers, heartburn, diarrhea, fluid retention and in rare cases, kidney dysfunction and cardiovascular disease.

And in light of potential drug interactions, many drugs can’t be taken in conjunction with NSAIDs. One study that reviewed the evidence from 65 NSAIDs trials found that NSAIDs were effective for short-term symptomatic relief in patients with acute and chronic low back pain without sciatica (pressure on the sciatic nerves down the legs, which causes pain). However, effect sizes were small.

Analgesic Medications

Specifically designed to relieve pain, analgesic medications include OTC acetaminophen and aspirin. Outcomes are controversial, given the risk of hypertension and other side effects, and the relief tends to be small to negligible, although there is some research that supports their short-term efficacy.

Prescription Opioids

Analgesics also include prescription opioids such as codeine, oxycodone, hydrocodone and morphine.

“Opioids as a group expose people to the risks of tolerance and addiction,” says Santhosh Thomas, DO, who specializes in orthopedic surgery of the spine at the Cleveland Clinic in Ohio. “They should be used in conjunction with some other intervention. Opioids shut off signals to the brain and can dull pain, but they don’t fix the problem.” Ohio, he points out, has a registry to track medication and determine if use/prescription is appropriate.

Dr. Thomas also recommends long-acting opioids (LAO) rather than short-acting opioids (SAO) because LAOs release the drug more gradually into the bloodstream so as not to cause a rapid increase and decrease in serum levels.

It’s also difficult for doctors to prescribe opioids, Dr. Hazard says, as there are no fixed guidelines for dosage. “People respond so differently,” he says. Some people are very sensitive; others have a very high tolerance.

Aside from the obvious risks for increased drug tolerance, abuse and addiction, Dr. Hazard says that other common side effects of opioids are headaches, sedation, constipation, hypogonadism, decreased reaction time and impaired judgment. For long-term opioid use, says Hazard, you need to have a steady relationship with your provider. Dartmouth developed a Safe Opioid Use Program 15 months ago that develops contracts between providers and patients, carefully tracks usage and instigates spot urine checks.

Anticonvulsants

Drugs primarily used to treat seizures may be useful in treating people with radiculopathy and radicular pain, a pain caused by nerve damage. They work by causing changes in the electric signals in the brain. Anticonvulsants most often used to treat chronic pain are carbamazepine (Tegretol) and gabapentin (Neurontin). The most problematic side effects are dizziness and drowsiness.

Antidepressants

Tricyclics and serotonin and norepinephrine reuptake inhibitors are commonly prescribed for chronic low back pain to provide pain relief, help with sleep and reduce depression. Antidepressants may increase neurotransmitters in the spinal cord that reduce pain signals. However, their benefit for nonspecific low back pain is unproved, according to the most recent review of studies assessing their benefit. Like anticonvulsants, one of the biggest risks is sedation.

Epidural steroid injections

Steroid injections are a commonly used short-term option for treating low back pain associated with inflammation. Pain relief tends to be temporary and there is a low risk of spinal infection and nerve damage as well as the more frequent spinal tap and headache. In a 2012 study, patients given steroid treatments didn’t experience much pain relief in either the short or long term, nor did researchers find a significant difference in pain relief when they compared patients who had received steroid injections with those who didn’t.

Your Best Drug-Free Treatment Options

As the tide turns against medication as a viable solution for back pain, alternative treatments such as physical therapy, core strengthening, exercise and massage have emerged as effective strategies.

“Medications don’t have a whopping track record,” says Dr. Hazard. “Intensive rehabilitation does. It’s a multidisciplinary approach called Functional Rehabilitation that includes occupational therapy, physical therapy (PT), physical training, counseling and instruction in pain management.”

Dr. Thomas cites PT as the earliest intervention he recommends his patients to try, along with lifestyle changes such as weight loss and kicking smoking.

Massage

A 2011 study published in Annals of Internal Medicine Massage showed that participants in massage groups reported greater average improvements in pain and functioning compared to those in the usual care group that included a range of options: taking pain medications or muscle relaxants, seeing doctors or chiropractors, physical therapy or simply not doing anything. No clinically meaningful difference between relaxation (Swedish) and structural massage was observed in terms of relieving disability or symptoms, however.

Soft tissue work can be surprisingly effective at relieving pain, says West. He recommends finding a practitioner experienced with pathology and musculoskeletal issues.

Physical therapy

A study published in February 2009 recommends that in most cases of symptomatic lumbar degenerative disc disease, a common cause of low back pain (LBP), the most effective treatment is physical therapy combined with anti-inflammatory medications. Exercise and manual therapy including spinal manipulation as well as educating patients in the use of appropriate body mechanics has a good track record of benefit.

Victor Hoover, a 43-year-old engineer based in Corpus Christi, Texas, who has suffered from back pain almost daily for roughly two decades, says he’s tried everything to help relieve it. What works best, he says, is a foam roller. Foam rollers, popular among PTs, untie the knots in your muscles by breaking down adhesions and helping to heal the tissue.

“It’s like aggressive physical therapy,” says Hoover. “For me, it’s worked better than stretching or light exercise, and I do it several times a week before I go to bed. Nothing else has lasted as long, in terms of benefit.”

Some physical therapists might try transcutaneous electrical nerve stimulation (TENS) for short-term pain. The treatment, which stimulates nerves around the spine in an attempt to change the messages sent to your brain’s pain receptors, isn’t painful but hasn’t been shown to be effective treatment for chronic pain.

Exercise

Yoga for Back Pain“Prevention is by far the best way to prevent back pain,” says West. And not sitting is high on the list. You shouldn’t sit more than 20 minutes at a time without a movement break and strategize ways for not sitting for long periods of time, even when taking into account the time you spend driving.

If it’s too late for prevention, low-impact exercise can help reduce your pain. Walking and swimming are two non-jarring activities doctors and physical therapists recommend. Also note that toned abdominal muscles are essential for back health (they help create a natural “girdle” that helps support your spine): Pilates, yoga or specific, targeted exercises (such as “swimming” moves that strengthen the back muscles) that support your spine are good ways to keep your core strong and reinforce your alignment awareness.

Eric Volk, a stay-at-home dad and part time marketer who lives in Lyons, Colorado, describes yoga as “poor man’s massage, because you have to do the work yourself without the help of a massage therapist.”

Ideally, proper alignment of your body, the best defense against backaches, is integrated into all of one’s movements, including everyday activities such as walking, lifting, bending and gardening.

Relaxation and Meditation

There’s some evidence that mind-related techniques, including hypnosis, meditation and biofeedback can be effective additions to a chronic pain management program; ask your doctor or physical therapist for advice or referrals.

Surgery

Many doctors discourage patients from surgical treatment for chronic back pain. Surgical treatments should be considered a last resort, says Dr. Thomas, and only considered after all other treatments have failed to provide relief. Even then, surgery does not provide significant improvement for everyone and is associated with serious risks.

These are the 3 most common surgical procedures for back pain:

  • Spinal laminectomy (also known as spinal decompression) Laminectomy is performed when spinal stenosis causes a narrowing of the spinal canal that causes pain, numbness or weakness. The surgeon removes part or all of the vertebral bone (lamina) to relieve compression of the spinal cord or the nerve roots to remove pressure on the nerves. Reported outcomes vary, but the American Academy of Orthopaedic Surgeons estimates that 80% of such surgeries are successful.
  • Diskectomy In a diskectomy, surgeons remove the damaged portion of a herniated disk in your spine. Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.Volk first experienced back pain at age 17. He is now 38 and has had two laminectomy/discectomy operations. His first, when he was 29, was considered a success. However, the disc weakened and was compromised — he had a recurrent disc herniation several years later. After a second surgery 6 years later, his back was still in bad shape. His doctor recommends spinal fusion, but Volk fears that the more invasive surgery can ultimately lead to disk deterioration.
  • Spinal fusion Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Success is dependent on many factors, but the rate of improvement after the surgery is between 60% and 90%, according to the University of Rochester Medical Center.Being a smoker, for example, can diminish chances that back surgery is successful. Cigarette smoking causes a number of problems for patients undergoing spinal fusion, including a significantly decreased rate of successful fusion (called nonunion or pseudarthrosis).“We won’t operate on smokers with spine-related issues because of the higher failure rate,” says Dr. Thomas.Note that spinal fusion might result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. The procedure also has been associated with an acceleration of disc degeneration at adjacent levels of the spine.Also worth noting: CBS News reported in 2014 that the number of spinal fusion surgeries performed rose 70% between 2001 and 2011, raising questions about how many of those operations might have been medically unnecessary.

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