Back Pain Health Article

Treatment team

Internists and general practitioners are often the first to see patients with back pain. Depending on the cause and severity of pain, neurologists, orthopedists, physical medicine specialists, pain management specialists, psychologists, psychiatrists, and other medical specialists may offer evaluation and treatment. Physical therapists, chiropractors, acupuncturists, vocational rehabilitation counselors, and radiology technicians may all become involved in management.

Treatment

Most cases of acute musculoskeletal back pain respond in a few days or weeks to limited rest, combined with appropriate exercise and education on correct movement patterns to avoid further injury. However, many cases resolve on their own without any treatment during a similar time period.

Although acute back pain was previously treated with complete, prolonged bed rest, this is no longer recommended because it leads to muscular deconditioning and loss of bone calcium, which can make the situation worse. Other complications of bed rest may include depression and blood clots in the legs. In 1996, a Finnish study showed that an exercise program to improve back mobility, coupled with resumption of normal activities and avoidance of rest during the day, allowed better back range of motion by the seventh day than did a program of strict bed rest.

Current wisdom is to limit bed rest for low back pain to one day, beginning immediately after injury or acute onset of pain, followed by resuming activities as soon as possible. While resting or sleeping, the best positions are on one side with a pillow between the knees, or on the back with a pillow under the knees.

Exercise speeds up recovery, reduces the risk of future back injuries, and releases the body's natural pain relievers known as endorphins. Doctors may suggest specific back exercises; aerobic exercises that improve conditioning without undue stress on the back include walking, stationary bicycle, and swimming or water aerobics. Any exercise program should be started slowly and built up gradually. Discomfort during exercise is not unusual, especially when starting out. However, patients experiencing pain of moderate or greater severity or lasting more than 15 minutes during exercise should stop exercising and inform their physician.

Local application of an ice pack or heat to the painful area, or use of muscle balms containing menthol, eucalyptus, or camphor may reduce inflammation, feel soothing, and facilitate exercise. Cold packs are recommended within the first 48 hours after back pain begins, with use of hot packs subsequently.

For back pain following an injury, physical therapy may offer strengthening programs and education in posture, movement patterns, and lifting techniques that protect the back to avoid further injury. Exercises designed to increase flexibility, tone, and strength help to replace fluid into dehydrated discs. Ultrasound, moist heat application, hydrotherapy involving pools or spas, or massage of painful areas may relieve pain and spasm, increase local circulation, and improve mobility.

Transcutaneous electrical nerve stimulation (TENS) uses a battery-powered device generating weak electrical impulses applied along the course of affected nerves to block pain signals traveling to the brain. This technique may also stimulate production of endorphins, or naturally occurring pain relievers, by the brain.

Although traction, or spinal stretching using weights applied to the spine, was once thought to decrease pressure on the nerve roots, this treatment has not been proven to be effective and is now seldom used.

Nonsteroidal anti-inflammatory drugs (NSAIDs) may relieve pain by reducing inflammation. These include naproxen (Aleve) and ibuprofen (Nuprin, Motrin IB, and Advil). Because these drugs may cause gastrointestinal bleeding, patients with ulcers, bleeding disorders, or other gastrointestinal conditions should avoid them. Other side effects may include kidney damage, and salt and fluid retention leading to high blood pressure.

COX-2 inhibitors are a more recently developed class of prescription drugs that reduce pain and inflammation with fewer gastrointestinal effects than the NSAIDs. These include celecoxib (Celebrex) and rofecoxib (Vioxx).

For severe back pain caused by inflammation of nerve roots or other structures, steroids may be injected directly into the inflamed area, often combined with local anesthetic. These can be epidural injections targeting the nerve roots, or trigger point injections into tender areas of muscle.

Other medications that may be indicated include analgesics or pain relievers such as aspirin or acetaminophen (Tylenol), muscle relaxants, antidepressants, or antiepileptic drugs. Muscle relaxants such as cyclobenzaprine (Flexeril), carisoprodol (Soma), and methocarbamol (Robaxin) may relieve painful spasms, but may also cause drowsiness and should not be used when working, driving, or operating heavy equipment.

Some antidepressants, especially when given in low doses, act as pain relievers in addition to reducing symptoms of depression and insomnia. Among these medications are tricyclic antidepressants such as amitriptyline and desipramine; and newer antidepressants such as the selective serotonin reuptake inhibitors (SSRI)s are being tested for their ability to relieve pain. However, a review of studies published in November 2003 suggests that the tricyclic antidepressants, but not the SSRIs, reduce pain symptoms. Although antiepileptic drugs are primarily used to treat seizures, they have a stabilizing effect on nerve cells that makes them effective for certain types of nerve pain.

For severe pain, opioids and narcotics such as oxycodone-release (Oxycontin), acetaminophen with codeine (Tylenol with codeine), and meperidine (Demerol) may be prescribed. However, they may be addicting and associated with troublesome side effects including constipation, impaired judgment and reaction time, and sleepiness. Therefore, these drugs should only be used under a doctor's supervision, only when other medications are ineffective, and only for limited periods. Some pain management specialists believe that habitual use of these drugs may worsen depression and even increase pain.

In some patients, spinal manipulation, also known as osteopathic manipulative therapy or chiropractic, may correct patterns of spinal imbalance that impedes recovery. It may be helpful during the first month of low back pain, but it should be avoided in patients with previous back surgery, back injury related to underlying disease, and back malformations. Before proceeding with chiropractic, it may be wise to get clearance from a medical doctor.

Acupuncture is an alternative medicine technique in which trained practitioners place very-fine needles at precisely specified body locations to relieve pain. Insertion of these needles is thought to unblock the body's normal flow of energy and to release peptides, which are naturally occurring pain relievers. Clinical studies are underway to compare how effective acupuncture is relative to standard treatments for low back pain.

Biofeedback is a treatment recommended by some pain specialists, in conjunction with other treatments. By placing electrodes on the skin and connecting them to a biofeedback machine, the patient learns to modify the response to pain by controlling muscle tension, heart rate, and skin temperature. Meditation or other relaxation techniques may enhance the response to biofeedback training.

Patients who do not respond to the above treatments may be candidates for back surgery if there is a clear abnormality in structure that could be corrected surgically. Although surgery is typically a last resort, it may be done on an urgent basis if the spinal cord or nerve roots are being compromised.

Discectomy is a surgical procedure to relieve pressure on a nerve root caused by a bulging disc or bone spur, whereas foraminotomy enlarges the bony hole, or foramen, where a nerve root enters or exits the spinal canal. In spinal laminectomy, or spinal decompression, a piece of the bony roof of the spinal canal known as the lamina is removed on one or both sides to increase the size of the spinal canal and reduce pressure on the spinal cord and nerve roots.

Spinal fusion stabilizes the spine and prevents painful movements, but with resulting loss of flexibility. The spinal discs between two or more vertebrae are removed, and the neighboring vertebrae are joined together with bone grafts and/or metal devices attached by screws. To allow the bone grafts to grow and fuse the vertebrae together, a long recovery period is needed. The Food and Drug Administration (FDA) has approved the intervertebral body fusion device, the anterior spinal implant, and the posterior spinal implant for use in this type of procedure.

To relieve severe chronic pain, spinal cord stimulation devices may be surgically implanted. These devices discharge electrical impulses to stimulate the spinal cord and to block the perception of pain. Other procedures used as a last resort cut nerve fibers to relieve pain, but patients may find the resultant altered sensations more troubling than the pain itself. Rhizotomy involves cutting the nerve root near its point of entry to the spinal cord. Cordotomy destroys bundles of nerve fibers on one or both sides of the spinal cord, and dorsal root entry zone (DREZ) operation severs spinal neurons.