Best Treatment Guidelines For Back Pain From Rest To Surgery

Best treatment guidelines for back pain from rest to surgery

An aching the back can have many people reaching for a heating pad, ice pack or phone to call the doctor.

Lower back pain is the No. 2 reason people call their doctor, behind colds and flu. Most need not worry. Typically, it’s a combination of the natural aging process and a strain or a sprain that causes the pain.

Unless the pain is radiating down the leg or there is numbness, tingling or weakness, “symptoms go away in a couple days without doing much of anything,” said Dr. Mark A. Knaub, director of the Orthopaedic Spine Service at Penn State Milton S. Hershey Medical Center.

Radiating pain and weakness can signal a more serious injury involving pressure on the nerve and those individuals should consult their doctor within a few days.

While patients often point to a specific activity that caused the pain, doctors can’t always easily diagnose the exact problem.

“We do not have a diagnostic test that has a flashing red light that says, ‘Here’s where the pain is,’” Knaub said. “With degeneration changes, people develop bulging disks, arthritis — they’re present in everyone as we age. Almost everybody has them but not everyone has symptoms.”

While some aggressive treatment options have expanded in the last 20 years, such as injections, minimally invasive procedures, and surgery, standard conservative the treatment has not changed much, Knaub said. Exercise and conditioning, medication, physical therapy, and chiropractic care are among the standard options.

“We’re no better at diagnosing it now and sadly, we’re not better at treating it despite having more options,” Knaub said. “We tend to treat more aggressively and spend more money, and it doesn’t make it better in terms of how the patient feels. “As a society, we’ve become less tolerant of having any pain. Everyone wants a fix,” he added. “They’re frustrated because they think there should be a cure. My take-home message for most people is that there isn’t.”

Here are some of the more common treatments for low back pain:

Rest and pain relief

Basic treatment relies on the old standbys: relative rest, heat, ice, pain relievers.

“Relative rest is backing off activity and that’s probably the most important part,” Knaub said. In the past, back pain was treated with bed rest, and “we learned that’s not the right thing to do.”

Use pain relievers like Tylenol or anti-inflammatories such as Aleve or Motrin, and apply either heat or ice.

“There’s no scientific evidence that one is better than the other. It’s whatever makes it feel better,” said Knaub, who keeps heat wraps on hand for his back flares.

Chiropractic care

Many backs pain patients try chiropractic care, which provides spinal manipulation to align the spine and manual therapies.

More than 18 million adults receive chiropractic care in the U.S., according to 2007 National Health Interview Survey, but myths persist, said Dr. Matt Boland, whose chiropractic practice in Lower Paxton Twp. offers nonsurgical orthopedic care with a medical doctor and a nurse practitioner.

“There’s no cracking, no popping, no hurting,” Boland said. “Think of this like taking your car to the mechanic when your engine is not working quite right. You’re getting an adjustment.”

Patients with chronic back pain might see a chiropractor 20 to 30 times over three to four months. “Once you’ve had [a back] issue, it’s not something you fix and forget about,” Boland said. “You manage it over time.”

Physical therapy

Physical therapy can be used following surgery, as a standalone treatment or as an adjunct to other treatments.

“We are looking to do the hands-on treatment right away to address the problem, improve range of motion and mobility and look to correct deficits in flexibility and strength,” said Michael Gilbert, doctor of physical therapy at Madden Physical Therapy in Lower Paxton Twp.

Depending on symptoms, some patients may benefit from hands-on mobility or manipulation to the pelvis and lumbar spine to help restore normal movement, others focus on strengthening the lumbar and spinal muscles and some could benefit from mechanical lumbar traction which stretches the lower back.

“We are using their body mechanics and principles to alleviate pain and get well,” Gilbert said.

Treatment typically runs between 10 and 12 visits, and patients should follow at-home exercises to maintain results.

Alternative medicine

2009 study shows acupuncture can be more helpful for back pain than traditional methods.

“It’s a good tool for people who are willing to take partnership in their healing,” said Rhonda Giddings, president and founder of Giddings Acupuncture Practice in Lower Paxton Twp.

The study in the Archives of Internal Medicine compared three acupuncture techniques, including a fake technique that used only toothpicks, to standard back pain treatment. Overall, 60 percent of acupuncture-treated patients — including the “sham” technique users — registered improvements but just 39 percent of the usual care group did.

Acupuncture focuses on the body’s qi (pronounced chee), or energy, that flows along pathways called meridians. By inserting needles into specific points, the qi can be directed to flow properly and restore health.

The needles “don’t cut tissue, they push it,” said Giddings who prefers no more than 15 to 18 needles. “There’s no reason to look like a porcupine.”

Treatments typically last from 10 to 12 visits, and eventually, the time between visits is lengthened to recommended maintenance treatments about five times a year.

Injections and surgery

Spinal injections can be used to help find the source of pain and for pain treatment, but usually only after more conservative treatments have failed. Most common are epidural injections of a cortisone medication, which could relieve pain for weeks or months while other treatment methods continue, according to the San Francisco Spine Institute.

For long-standing back pain, one newer treatment is radiofrequency ablation, which delivers electrical stimulation to specific nerves to desensitize them or delivers enough electricity to destroy the nerve, according to WebMD. A similar procedure delivers heat to a herniated disk to shrink it.

Back surgery might ultimately be recommended, but even it is not a cure-all.

People who respond best to surgery, with an 80 percent to 95 percent success rate, have nerve involvement, Knaub said, such as pinched nerves from disk herniation, spinal stenosis, and compression of the spinal cord.

“For run-of-the-mill back pain … surgery is not likely to make you better,” he said. “I try to talk people out of operations more than I convince them to have them.”

The success rate for those cases falls to 40 percent to 50 percent, he said.

The overall rate of lower-back surgery among older Americans declined slightly from 2002 to 2007, but a recent study in the Journal of the American Medical Association found a 15-fold increase in the rate of more complex and expensive spinal fusions.

The study suggested aggressive marketing by implant makers and greater physician compensation for high-tech procedures may be to blame.

One A 55-year-old Midstate administrator understands the gray areas in spinal surgery outcomes. She has tried various treatments for pain from arthritis in her spinal canal, herniated disks and spinal stenosis and is now recuperating from her second major surgery in 19 years.

Muscle relaxers and pain pills preceded her arthritis diagnosis and she was counseled to walk, swim and not gain weight, said the woman, who declined to be identified. But one day in 1991, she awoke and couldn’t get out of bed.

Her first surgery repaired herniated disks in three places, removed calcification, and opened the spinal canal to relieve pinching. She followed a water therapy regimen, missed work for six months, and learned how to sit, stand, and lie differently.

Over time, she periodically suffered muscle spasms but the last two years experienced increasing pain. After anti-inflammatory injections, muscle relaxers, and heat and cold therapy, she was diagnosed with cervical spine stenosis and two more herniated disks.

Surgery this time packed more of a wallop. “I had no feeling in my left leg. I didn’t know that until I tried to stand. It’s like nothing was there,” she said.

Two months later, she has shed the hospital bed, walker, and cane, uses steps unaided, and takes regular walks but she still doesn’t know what the future holds.

“There’s no guarantee it’s my last surgery,” she said. “I’m hopeful, but I can’t stop arthritis from growing.”

WHAT YOU SHOULD KNOW ABOUT BACK PAIN

Back pain can be one of the most debilitating kinds of pain, but most people get better with time.

· See a doctor quickly if the pain is accompanied by “red flag” symptoms that include trouble urinating, leg weakness, numbness or pain, fever or unintentional weight loss.
· With run-of-the-mill back pain, allow a month to six weeks to see if it goes away on its own.
· Don’t expect an X-ray or MRI before then unless the doctor suspects a serious problem.
· Try over-the-counter pain relievers such as aspirin or ibuprofen. Heating pads and firm mattresses also are recommended.
· If the pain doesn’t go away in six weeks, ask about rehabilitation or exercise therapy. There are specific exercises recommended for different kinds of pain.
· If surgery is recommended, ask why that’s the best option, what are the risks and what would happen if you don’t operate — what other options you might try instead. Seek a second opinion. Your doctor or insurer also might offer “decision aids,” DVDs or booklets that describe the pros and cons of each option.

BEST WAYS TO PREVENT BACK PAIN

· Avoid tobacco use.
· Lose weight or maintain a normal weight.
· Strengthen core muscles — abdominals and lower back muscles.
· Engage in regular cardiovascular exercise, as little as walking the dog three or four times a week for 30 minutes.
· Maintain flexibility through legs and lumbar spine through regular stretching.
· Weekend warriors should try to incorporate the movements of their weekend sports into several weekdays. Sitting at a desk all week can shorten and tighten a person’s leg and lumbar spine muscles and they won’t provide the range of motion they did in high school.