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Back Pain
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Apr 9 17:34 UTC 2001 |
Consumer Reports On Health, May 2000
Back pain: Does anything work? (Unnecessary, ineffective, even harmful
treatments abound. Here's what may be worth trying - and what to avoid.)
In a recent survey of some 47,000 Consumer Reports readers, back pain
was the most common physical complaint - and almost at the top of our
"misery index," a rating of how painful various conditions are.
Fortunately, bouts of back pain usually get better on their own.
Unfortunately, they often get better slowly, and there's no proven way
to substantially speed healing, beyond simple self-help steps. That
creates temptations for practitioners and pitfalls for patients. In one
recent study, for example, where doctors talked candidly in focus
groups, they acknowledged that they sometimes order X-rays or MRI
(magnetic-resonance imaging) tests of questionable value, mainly to
reassure back-pain patients that they were trying to do something.
Meanwhile, the lack of effective medical treatments drives many patients
to look elsewhere. In the Consumer Reports survey, 54 percent of
readers who had experienced back pain said they'd tried chiropractic
manipulation, deep massage, acupuncture, or some other alternative
therapy.
Chiropractors and possibly physical and massage therapists may be able
to treat acute back pain - an isolated incident lasting less than a
month or so - slightly better than medical doctors can. But the costs,
at least for chiropractors and physical therapists, are much higher than
for conventional therapy - in part because of the protracted treatments
those practitioners often recommend and the X-rays chiropractors often
order.
The stakes increase when back pain becomes chronic, lasting longer than
a month or so. Many people with such pain undergo surgery, which can
help in many cases. But that help is often limited. And the operation is
sometimes performed prematurely, when other options might have worked,
or needlessly, when surgery can't help at all.
Here are the facts that can help you treat yourself, decide whether and
when to see a doctor or other practitioner, and protect yourself against
superfluous or ineffective tests and treatments.
TOO MUCH TESTING
Back pain usually stems from a strain, or minor tear, of the muscles and
ligaments that support the lower back. Sometimes a specific incident -
for example, bending or twisting in an awkward manner or lifting a heavy
object - causes the injury. More often, the strains seem to just
happen, perhaps due to bad posture or even emotional stress. Apart from
strains, the most common causes of low-back pain are arthritis of the
spinal joints; spinal stenosis, or bony overgrowths that narrow the
spinal canal; and a bulging or herniated disk, where one of the spinal
cushioning pads protrudes beyond the vertebrae.
Different causes of back pain often produce similar symptoms. To try
pinpointing the cause, many practitioners order X-rays or MRI tests. But
in most cases of acute back pain, those tests are needless and possibly
harmful.
First, imaging tests seldom do identify what's causing the pain. Muscle
strains are seldom detected by an MRI and never detected by X-rays. Back
X-rays can suggest spinal arthritis or stenosis, and an MRI can confirm
them. But those problems are actually harmless in the vast majority of
cases; in fact, they're almost as common in people who don't have back
pain as in those who do. Similarly, an MRI reveals a protruding disk in
up to 70 percent of asymptomatic people; that's because the protrusion
causes pain only in the few cases where it actually presses on a spinal
nerve.
Even if the cause of acute back pain could be identified, that
information usually would not influence the proper choice of treatment.
Regardless of the cause, doctors generally advise the same steps -
mainly painkillers, icing and heat, and gentle exercise - for acute back
pain.
Avoiding needless tests is important. For one thing, back X-rays expose
you to 20 times more radiation than chest X-rays or mammograms. And
needless X-rays or MRIs may lead to needless treatment, such as surgery
to correct a harmless "abnormality."
Chiropractors often use X-rays to spot "subluxations," supposed spinal
misalignments that they say influence back pain and many other aspects
of health. And they often use those results to recommend repeat visits
after the pain has subsided, to correct the subluxations. But there's
little if any scientific evidence on whether further treatment after
recovery from the pain can actually help prevent recurrence - or provide
any other health benefit. Of course, needless tests also create
needless costs: typically about $300 for X-rays and $2,000 for an MRI,
although both are usually covered by insurance.
In general, you should undergo an X-ray or MRI for acute back pain only
if you have one or more of the following signs of a potentially serious
problem:
- A recent accident, or a history or high risk of osteoporosis.
(Possible problem: spinal fracture.)
- Unexplained weight loss, a history of cancer, or incontinence.
(Possible problem: spinal cancer.)
- Fever, night sweats, or a recent bacterial infection. (Possible
problem: spinal infection.)
- Severe or progressive leg weakness, or pain radiating from the back to
the lower leg. (Possible problem: a badly protruding disk, or a tumor.)
- Age 70 or over. (That makes cancer, osteoporotic fractures, and
infection more likely).
TREATMENT: LIMITED OPTIONS
The standard treatment for an acute bout of back pain is so
straightforward that you can usually do it on your own. Take an
over-the-counter, nonsteroidal anti-inflammatory drug (NSAID) such as
aspirin or ibuprofen (Advil, Nuprin) to relieve pain and reduce
inflammation. (If that doesn't help, ask your doctor about prescribing a
stronger drug. Corticosteroid injections might be worth considering for
very severe, immobilizing pain, although no clinical trial has tested
whether they actually work.) Apply a cold pack to reduce pain and
swelling during the first day or two, then a heating pad, set on low.
(Deep-heating creams may ease pain temporarily - but never use them with
a heating pad.)
Don't rest in bed for more than a day or two, since inactivity tends to
worsen the problem. Once the worst is over, stretching plus gentle
aerobic activities like walking, swimming, or bicycling can help.
Exercises to strengthen the abdomen or back don't seem to speed
recovery, but they may help prevent recurrence. (See "Exercises to beat
low-back pain" and "For more information," below, for details on
exercises for the back.)
With nothing more than simple self-help steps, some 60 percent of people
with acute back pain get better within a week, 90 percent within a
month. (Even the pain of a protruding disk usually resolves on its own
within six weeks, as the protrusion shrinks.) But many people want
faster relief than those self-help steps afford. Or they want to avoid
NSAIDs, which can cause gastrointestinal side effects. The treatments
that physicians used to offer - traction, corsets, and transcutaneous
electrical nerve stimulation, (TENS), or application of a mild
electrical current to the skin over the painful area - have all been
discredited, leaving doctors with no established options for acute back
pain other than strong medication and the usual conservative steps.
(Preliminary research does suggest that a version of TENS called
percutaneous electrical nerve stimulation (PENS), which delivers the
electricity through acupuncture needles, may offer some relief.)
The evidence that acupuncture or relaxation therapy eases back pain is
generally weak. There's even less support for other alternatives, like
magnets and supplements such as glucosamine and chondroitin.
WHAT ABOUT HANDS-ON CARE?
Not surprisingly, frustrated patients often turn to practitioners who
can provide direct manual treatment. That usually means chiropractors,
physical therapists, or massage therapists.
Chiropractors aim to restore range of motion and ease pain primarily by
manipulating, or realigning, the spine, often by applying short,
powerful thrusts. (Some osteopathic physicians - who derive from the
same tradition as chiropractors but now receive a complete medical
education - also manipulate the spine.) Massage therapists often treat
back pain with one of four aggressive methods: deep-tissue massage,
myofascial release, or rolfing, all designed to stretch the muscles and
connective tissue by applying steady, even slightly painful pressure;
and neuromuscular massage, where strong pressure is applied to painful
knots in the muscles. Physical therapists may combine massage and
perhaps manipulation with advice on exercise, posture, and body
mechanics.
People clearly like such hands-on care. In the Consumer Reports survey,
the percentages of readers who said that specific treatments made them
feel much better were 49 percent for chiropractic treatment, 43 percent
for deep-tissue massage, and 35 percent for physical therapy, compared
with 25 percent for prescription drugs.
Many studies of manipulation and the few studies of physical therapy or
massage have suggested that such treatments may ease acute back pain.
However, the best studies of chiropractic or physical therapy have
generally found only slight improvements in pain, mobility, or recovery
speed. (No rigorous study of massage for back pain has been published.)
In the largest of the well-designed studies, published recently in The
New England Journal of Medicine, researchers randomly assigned some 320
people either to visit a chiropractor or physical therapist or to
receive a booklet containing the standard advice. Those treated with
manipulation or physical therapy showed only marginally less pain and
restricted motion than those who merely received the advice.
Moreover, the rate of recurrent back pain over the next two years was
the same in both groups, a finding confirmed by other research. For
example, a recent two-year study from the University of North Carolina,
involving more than 900 people with acute back pain, found that slightly
over half of the patients experienced a relapse, whether they initially
saw a chiropractor or a medical doctor.
In addition, the study in The New England Journal of Medicine found that
chiropractic care and physical therapy each typically cost about three
times as much as standard therapy, mainly because those treatments
require more visits to a practitioner. With chiropractors, some of that
higher cost comes from the X-rays. A recent survey conducted by the
American Chiropractic Association found that 69 percent of its members
routinely use X-rays before treating back pain; in contrast, only about
20 percent of primary-care doctors follow that practice.
Jerome F. McAndrew, former president of the American Chiropractic
Association, says the X-rays serve mainly to rule out any condition,
such as a tumor or fracture, that might make manipulation dangerous. But
complications of spinal manipulation are extremely rare, so it's
unclear whether complications or the X-rays themselves pose the bigger
threat.
SURGERY FOR CHRONIC BACK PAIN?
If the pain doesn't clear up in a month or so, the pain may be becoming
chronic, and X-rays and possibly MRIs are now necessary, mainly to rule
out a tumor or other underlying disease. If there's no such disease,
most people with chronic back pain should try exercise first. In fact, a
targeted exercise regimen could save many people from undergoing
surgery.
In one recent study, Minnesota researchers recruited 60
chronic-back-pain patients who'd been told to have surgery to treat
either a protruding disk or spinal stenosis. Instead, the researchers
asked them to undergo a ten-week back-strengthening program. Sixteen
months later, 35 of the 46 patients who completed the program were still
getting along without surgery. (To develop an exercise program for
yourself, see "Exercises to beat low-back pain" and "For more
information" - or see a physical therapist.)
If exercise doesn't help, spinal manipulation or massage therapy might
be worth considering - despite the fact that the evidence that they work
is weaker for chronic back pain than for acute pain.
There are several reasons to try the nonsurgical options first. For one
thing, while back surgery relieves chronic pain caused by herniation or
stenosis in 85 to 90 percent of appropriate cases, that benefit is
sometimes temporary. By the end of one four-year clinical study
involving some 126 people with painful herniation, those who simply
waited were experiencing no more pain, on average, than those who
underwent surgery - partly because the pain sometimes recurred after the
operation and partly because it sometimes eased in those who avoided
surgery. And there's even less known about the long-term efficacy of
surgery for spinal stenosis than there is for disk surgery.
Even when nonsurgical treatments fail, surgery should be done only when
the problem seen on MRI clearly conforms to the patient's symptoms. For
a protruding disk, the confirming symptom is clear-cut sciatica - pain,
usually with numbness and tingling, that radiates from the lower back,
through one buttock, to below the knee. For stenosis, the key symptoms
are back pain plus thigh pain and weakness, usually in both legs, that's
worse when you walk, particularly downhill.
Disk surgery usually entails a one-day stay in the hospital, six weeks
of recovery, and some risks, including a very small chance of death,
mainly from the general anesthesia. (Laparoscopic diskectomy, in which
the surgeon works through several small incisions, may speed recovery
slightly. But it still requires general anesthesia, its effectiveness
beyond one year is unknown, and it can't be used for severe or
hard-to-reach protrusion. Studies have found another alternative, laser
disk surgery, to be less effective than the standard operation.) Surgery
for stenosis generally involves a longer stay, lengthier recovery, and
greater risks than the disk operation, since stenosis surgery is usually
more extensive and the patients are older and frailer.
SUMMING UP
The following guidelines can help you get the optimal treatment for your
back. For acute pain:
- You can generally treat yourself, with nonprescription painkillers,
icing, heat, and, as soon as possible, gentle exercise. Doctors can do
very little to speed that process, and you'll almost always get better
on your own in one to four weeks.
- Avoid X-rays and MRIs unless you have clear signs of a potentially
serious problem (listed above) other than a protruding disk or spinal
stenosis.
- You could consider seeing a chiropractor, an osteopath, a physical
therapist, or a massage therapist. But see a physician first to rule out
potentially serious problems and possibly to provide a referral.
Moreover, be aware that the benefits of hands-on treatment are generally
small, that chiropractors are more likely than other practitioners to
order X-rays, and that such therapies can be expensive and are only
sometimes covered by insurance.
For chronic pain, lasting more than a month:
- Be sure to undergo imaging tests.
- In general, consider surgery only if strengthening and stretching
exercises (and possibly manual therapy) have failed, imaging tests
reveal a protruding disk or stenosis, and the symptoms described in this
report show that the problem seen on the tests is clearly causing the
pain. But bear in mind that the benefits of surgery may not last.
FOR MORE INFORMATION
- "The Back Pain Helpbook," by James E. Moore, Ph.D., and others.
Exercises for back pain plus general information on the condition.
Perseus Books, 1999. $15. To order, call 800-386-5656.
EXERCISES TO BEAT LOW-BACK PAIN
In the 19th and early 20th centuries, low-back pain was commonly treated
with exercise. Now researchers are reviving that neglected approach.
Studies in the past several years suggest that strengthening exercises
may help ease chronic back pain and prevent painful episodes as well.
Other research suggests that stretching exercises and aerobic activities
that don't jar the back - such as walking, swimming, and biking - may
also help relieve acute or chronic back pain and prevent recurrence,
too. The guidelines listed here can help most people who have back pain.
However, see a physical therapist if you want more detailed advice, if
exercising on your own doesn't help, or if you have symptoms of spinal
stenosis.
Begin stretching and low-impact aerobic exercises as soon as the pain
permits. (But stop if it becomes markedly worse during or after the
exercise.) Gradually work up to at least 30 minutes a day of gentle
aerobics. Doing the two stretches described below once or twice a day is
enough to start with, but you should add others to your routine,
ideally until you're stretching for at least 10 to 15 minutes a day -
though even the minimum will probably help prevent recurrence. You
could also gradually increase the duration or intensity of your
low-impact aerobic workouts.
Strengthening exercises during the first month or so don't seem to speed
recovery, and they may cause discomfort. But if the pain lasts longer,
it's worth trying to work through the discomfort, provided the pain
doesn't worsen.
Fortunately, it doesn't take much exercise to substantially strengthen
the back. For the average person, all that's required is one set a week
of the floor extensions described here; doing them twice a week can
maximize the gains. Once the pain subsides somewhat, adding the modified
sit-ups to your weekly routine can add further support by strengthening
the abdominal muscles. Performing 8 to 12 repetitions of those
exercises if you're under age 50 or so is the best way to build
strength and endurance. If you're older than that or it's too
uncomfortable, do 10 to 15 repetitions of a somewhat easier version of
the exercise. To keep building strength once you've hit 12 or 15 reps,
increase the difficulty as described below.
- Strengthening: Floor extensions. Lie face down on the floor with your
hands folded under your chin. Using your low-back muscles only, raise
your chest and shoulders about 10 degrees off the floor, then lower
them. If you can't do that, push down on the floor with your hands to
help raise yourself. As you get stronger, gradually build up until you
can hold your body about 30 degrees off the floor. To increase the
difficulty further, wear a weighted backpack.
- Strengthening: Partial sit-ups. Lie on your back, with knees bent and
palms face down at your sides. Slowly lift your shoulders and upper back
off the floor. Hold for a count of three, and slowly drop them back
down. To increase the difficulty, perform the maneuver more slowly, hold
a light weight on your chest, place your hands loosely behind your
head, or do the sit-ups on an incline, with your feet higher than your
head.
- Stretching: Leg pull. Lie on your back, with one knee bent and the
other leg flat on the floor. Keeping the small of your back pressed
against the floor, flex both feet toward your head and grip the bent leg
just behind the knee; gently pull it toward your chest until you feel
the stretch in your buttocks and lower back. Hold for 10 seconds, then
repeat with the other leg. When you can do that easily and without pain,
repeat with both legs, rolling your shoulders forward, tucking your
chin to your chest, and lifting your upper body a few inches off the
floor.
- Stretching: Hip rolls. Lie on your back with your knees bent, feet
flat on the floor, arms straight out to each side, and head turned to
the left. Now bring your knees toward your chest and, keeping them bent
at a 90-degree angle, slowly let them fall to the right until your right
leg rests on the floor. Relax and hold that position for 10 seconds.
Then bring your legs back toward your chest and repeat the maneuver in
the opposite direction.
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