A Primer on Back Pain

IN AN INTERVIEW with NPR, Harvard cancer specialist and New Yorker writer Jerome Groopman described his 20-year long battle with “excruciating” and sometimes “explosive” back pain.  The ordeal included two surgeries that failed to allay his suffering — and this is someone with access to the best medical resources.

What ultimately helped was back pain “boot camp,” created at New England Baptist Hospital in Boston by Dr. James Rainville, who explains that pain often has nothing to do with the mechanics of the spine.  “It’s a change in the way the sensory system processes information.  Normal sensations…produced by movements are translated by the nervous system into a pain message,” says Rainville.

As many as 25% of patients with acute back pain are in an endless loop of pain due to persistent hypersensitivity of the nervous system.  As a result, addressing the brain issues can often alleviate back pain better than direct treatment of the back itself (see  MyLittleBird’s story on the pain-brain connection.

A compelling reason for treating the brain first is that the back presents thornier problems.  Even when MRI scans reveal abnormalities, those are not necessarily the cause of pain.  For more than 95% of those with back pain — for many of whom the pain is “age-related” — surgery is not the best treatment.  In addition, back surgery can lead to more pain over time, compared to leaving the problem untreated.  And among back pain sufferers who have surgery, one in five ends up having more surgery.

Cognitive behavioral therapy (CBT), which appears at the top of Google lists for “back pain,” can help control how the mind manages pain by transforming negative thoughts, for example from “I hate this pain” to “I have dealt with this pain before.”  Other therapies directed at the brain include meditation and deep breathing.  Tai chi and yoga work on both mind and body:  one study group who took 12 weeks of yoga classes had fewer pain symptoms than a control group.

Over six weeks of regular visits to back pain “boot camp,” physical therapists trained in Rainville’s methods give exercises at slowly increasing intensities to improve the back’s strength and flexibility, while at the same time getting patients to believe their backs can sustain such increasing intensity.

Before heading to professionals, the common recommendation is to try DIY remedies for about three months.  Even when the pain first hits, bed rest is advised for only the most severe cases and then for three days max.  But 15-minute breaks to lie with the back flat can help at any point.

Some advocate ice under the back for the first 48 hours after an injury, then switching to heat.  Others suggest alternating the two — first one and then the other: cold reduces inflammation and acts as a local anesthetic by slowing nerve impulses; heat stimulates blood flow while inhibiting pain messages sent to the brain.

Another-inflammation reliever is NSAIDS (non-steroidal anti-inflammatories), among which the best for some is a “medical dose” of Alleve, two pills in the morning and two at night.  As spasms subside, gentle exercises can begin with cat/camel: arching the back in both directions, convex and concave, as well as to one side and the other like a wagging dog’s tail.

Next come low-impact exercises like walking and swimming.  As with the heat-cold combo, the best approach may be a trifecta that combines exercise and stretching along with yoga and massage.  (Acupuncture might help, although one study on several hundred people found that those who received simulated acupuncture, using toothpick taps, had the same relief as those getting the real thing — but both did better than patients who had nothing comparable.)

Strengthening the “core” is a major focus of back pain-relieving exercises, because “the torso is a combination of many muscle groups working together,” Frank Wyatt, exercise physiology professor at Missouri Western State University, told WebMD.  “When we strengthen the abdominals, it often reduces the strain on the lower back.”

Many Pilates exercises work on the core, as do back-pain programs such as “Foundation Training,” a regimen of exercises developed by chiropractor Eric Goodman, available on DVDs and YouTube.  The McKenzie Method uses core muscle contractions as well as arm motions to stabilize the trunk and extend the spine.

Some of the more difficult-to-follow advice for back pain sufferers includes avoiding whatever strenuous exercise caused the original pain, including gardening.  Also avoid excessive sitting, bending your neck toward your phone for too long and carrying excess weight.

Also hard to follow are pillow-placement recommendations for sleeping:  back sleepers should put pillows under their knees; side sleepers should place pillows between their knees; and stomach sleepers should switch to one of the other two positions.

With persistent pain, it might be time to target the pain’s source. A cortisone injection, called a nerve root block, can relieve irritated nerves.

If six months of “aggressive conservative treatment” fails, and if the pain makes it difficult to complete daily activities, surgery can treat herniated or bulging discs, which create cushions between the vertebrae, according to spine-health.com.  Surgery is advised especially when painful discs cause conditions like sciatica, in which pain radiates down the leg.

One surgical option, spinal fusion, creates a direct bony connection between the vertebrae to prevent painful motion of the discs. A recent alternative for some patients is artificial disc replacement, which removes painful discs and uses prosthetic implants to maintain motion.

One more focus for treating back pain is depression and anxiety.  Australian research found a 60% greater incidence of back pain among people with deep depression compared to those without the symptoms, possibly due in part to poor sleep and lack of exercise.  Explains Alex Moroz, associate professor of Rehab Medicine at NYU Langone Medical Center, on spine-health.com., “Your emotional state colors the perception of pain.”

— Mary Carpenter
Mary Carpenter is the Well-Being Editor of MyLittleBird. Read more about Mary.



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