as posted by Time Healthland April 25 2011 -
If you're experiencing your first really bad backache, you're probably panicking a little about the pain and its implications — what if it's cancer? What if it never goes away? My first piece of advice is, relax. Low back pain is very common. About 80% of American adults will miss work at some point because of it. And most of the time, it's neither permanent nor serious: 95% of backaches go away within six weeks, with no specific treatment. Following are 10 essential things to know about dealing with a bad back.
By Dr. Scott Haig Monday, April 25, 2011
1. Prevent or Treat Spasm First
Being anxious or stressed out about back pain — or stressed out in general — will increase your chances of muscle spasm, which is itself both a source of back pain and an amplifier of other sources of pain. In addition to psychological stress, caffeine, dehydration, lack of sleep and low sodium are also likely to increase spasm and cramping.
What does spasm feel like? When you're bent over to one side and just can't straighten up, that's typically muscle spasm. The "stiff back" that hurts more than usual is also likely to be the result of spasm. Your first order of business should be rest and heat, but read on for some other clever physical maneuvers that can be effective for both back pain and muscle spasm.
2. Listen to Your Body
If you know it's going to hurt to try to move that refrigerator right now, don't do it. Your pain will not lessen or recede any faster if you ignore it and fight your way through. Forcing yourself to bend, twist or lift makes things worse.
Take it easy when your back hurts. Sit or sleep in the most comfortable position you can find. In most cases this means lying on your back with three or more pillows under your legs so that the hips and knees are both flexed 80 to 90 degrees.
Walking can be pretty painful early on, so avoid it at first. As the pain subsides and you straighten, going for a walk — with nothing in your hands, feet pointing straight, head up — is usually beneficial.
Listen for danger signals from your body as well. Electrical pains radiating down your legs; numbness or weakness in the lower extremities or crotch; or any loss of bowel or bladder control mean its time to seek out a doctor. If so, skip ahead to Tip No. 5, and make the phone call.
3. Rest & Exercise
Rest, anti-inflammatory pain medicines like ibuprofen (Advil), naproxen (Aleve) or acetaminophen (Tylenol), and a few days time will resolve many backaches. Applying heat or cold on the back relieves some patients' pain. In the hot-versus-cold debate, I've had an equal number of patients benefit from one but not the other. (Sorry, there is no official medical answer.)
Stretches and exercises to relieve low back pain — the kind you read about in self-help books and magazines — can be great or terrible, depending on the exercise and what's causing the pain. If you're doing this on your own, it makes sense to play the odds when it comes to these therapeutic maneuvers. For safety and effectiveness I can recommend only two: see Tip No. 4, next.
4. Stretches: The 90-90 and the Belly Hang
When it comes to stretches, my best advice for the most common, "generic" backache is the "90-90" position: lying on the floor with your calves flat on a chair or other horizontal surface, hips at 90 degrees to your body, knees flopped comfortably apart till you are not using any muscle force to stay there. The idea is to rest your spinal muscles and hip flexors completely. With the small of the back flat on the floor, thighs roughly vertical and calves horizontal, the back muscles that have been straining all day to prevent painful motion can relax. A tall person needs some flat cushions to make the chair higher, a shorter person needs a lower chair — like the seating surface of a couch. A sturdy box of just the right height, covered with a blanket works well too. Arms should rest comfortably out to the sides, head flat on the floor. Once you settle in and get relaxed, stay in that position for 15 minutes. This breaks spasm in some muscles, opens up the nerve spaces and evens out the forces across the small joints of spine. If it feels good and gives any relief the first time you try it, continue to do it three times a day.
The other reliable maneuver is a belly hang. Do this when you feel "crooked," or if the pain is radiating into your buttocks. Go down on hands and knees, straighten your elbows and rock forward till your shoulders are over your wrists. Hang your head down and just let your belly hang loosely, as far down as it will go. Stay there for five minutes. This is a lumbar-extension maneuver, sort of the opposite of the 90-90. It is good for breaking painful contraction and spasm in the spinal extensor muscles. Those "backstraps" — the muscles that extend or "bend back" the spine — get a strong signal to shut off when the spine is being bent back already, which is what happens when you do the belly hang. It may also help massage a bulging disc back into place.
5. Know When to Seek Help
a. Insurance. Your policy probably won't pay for massage, postural therapies or acupuncture. It might pay for some physical therapy, except with a huge enough co-pay that you'll end up basically paying for it yourself. You might also have a high deductible, which again increases your out-of-pocket cost.
Further, HMOs usually make you see an internist or family doctor before you see a therapist or specialist. That means you'll have to make an appointment with your primary care physician first, wait for that, then make an appointment with the physiatrist or orthopedist he or she recommends, and wait for that. (See how it works? You have a pretty good chance of getting better by yourself in that time.)
HMOs typically pay very little toward chiropractic care, which — apologies, colleagues — is often an excellent, efficient way to get rid of a backache.
b. Severity. If you are utterly debilitated by your back pain, you need to see a medical doctor who can prescribe drugs. However, it is not recommended to take narcotics for low back pain for a host of reasons, the most important of which is that the drugs can and usually will make the pain worse if you stay on them for more than a couple of weeks. But if you need drugs, you do need to see a physician — who I hope will have the sense to use every means possible to get you off painkillers as soon as possible.
c. Risk. Yes, some backaches are caused by things that can kill you: an aneurysm, cancer, spinal infection, even kidney problems can present as back pain. M.D.'s are trained to watch out for these.
What are the common signs that something rare and risky may be causing your backache? Ask yourself: is it the same old backache you get every time you shovel the walk? Probably not risky. Does the pain get worse at night in bed, boring in like a toothache? That could be cancer or an infection. Weight loss and fever along with the bad back are very bad signs too. Is the pain sudden and severe, ripping down your back or into the groin? It could be aneurysm or kidney stone. This last scenario is one of the few back pain emergencies — go straight to the emergency department with this.
6. Who Treats Back Pain?
There is no shortage of health-care providers who treat back pain. Below is a partial rundown of who does what.
Doctors are divided into M.D.'s, who graduated from a traditional medical school, and D.O.'s (doctor of osteopathic medicine), who have pretty similar educational backgrounds, except with training in "osteopathic manipulation," which can be a quick, easy and safe way to decrease your back pain. Problem is, most D.O.'s don't actually practice much osteopathy with manipulation. They are under the same rules and financial pressures as M.D.'s, so they're likely to do what most M.D.'s will do: write you a prescription and send you to see someone else.
Orthopedic surgeons end up seeing bad backs a lot and they will usually give you sound advice on what to do. Most of us don't really specialize in low back pain, however; our focus is on surgery of other joints.
There are both orthopedic and neurosurgeons who call themselves "spine surgeons," but curiously, few of these docs want to see patients with low back pain — at least not right off the bat. Many in my area will not even give an appointment to a patient unless he or she has already had an MRI, which means they have to have seen some other doctor first.
About 1 patient in 50 with a backache actually needs an operation, and you should not be thinking about spine surgery for your pain unless at least one, or better two, qualified doctors have recommended it. Unless you have already had a back operation in the past, you probably should call someone other than a spine surgeon when your back hurts.
Neurologists end up seeing a good bit of back pain. Of the docs who treat low backs, they are typically the most likely to use oral steroids, which can be effective — but there are some scary side effects. If the pain is greater in your legs than your back (a condition known as sciatica), or if you have numbness or weakness in your legs or feet, seeking a neurologist's care is a good bet.
A physiatrist is, overall, the most appropriate doc to see for back pain. Physiatrists do everything but operate, and their training is largely in what you need: the diagnosis and treatment of bad backs. They like to do spinal injections; they almost always order physical therapy; they often use oral medications. Physiatrists comprise a varied bunch however, so you would be wise to get a recommendation from a doctor who has previously referred patients with good results.
Generalists in medicine, like family practitioners, internists and emergency room doctors, see a lot of back pain patients. They can prescribe all the appropriate tests and medications as well as physical therapy — but they are not likely to direct your physical therapy like an orthopedist or physiatrist would (the good news is that physical therapists usually do a pretty good job of deciding your treatment on their own). General practitioners vary a lot in terms of how involved they get with a low back pain case, but the internist is my second pick (after physiatrist) for the doctor to see first with a backache.
7. Chiropractors Versus Physical Therapists
Chiropractors are called "doctor" — though many of us who have actually struggled through medical school bristle at this. Like M.D.'s, some are honest, some are crooks. Chiropractic theory itself is, well, a little smoky. But a chiropractor's manipulative treatments, if applied with an earnest desire to reduce pain, often provide relief (albeit temporarily) for backache. I have gone to a chiro myself on more than one occasion and his treatment definitely took the edge off my pain for the rest of the day.
Physical therapists have to complete four years of legitimate and pretty hard postgraduate study to put R.P.T. (registered physical therapist) after their names. In some states, you need a referral from a doctor to see a physical therapist; in others, you can go directly to a P.T. for diagnosis and treatment of back pain. P.T.'s use a wide range of treatments, but I have hardly ever seen them use chiropractic manipulations, even though they're qualified to do them.
All kinds of semi-scientific studies have been done comparing chiropractic treatments to physical therapy; my unscientific meta-analysis of these has the chiros ahead by a nose. But to whom do my colleagues in orthopedics and I send back-pain patients most frequently? To physical therapists. In fact, physical therapy is the most common treatment used for backaches in my practice, the payment issues mentioned in Tip. No. 5 notwthstanding. Why? Patient acceptance, and the fact that P.T.'s are much more consistent than chiros in how they treat.
8. What Is Traction?
Traction is a well-recognized and traditional form of physical treatment that helps many patients. It's not such an easy problem applying longitudinal force to a human's lower half; the spinal decompression DRX machine and other computer-controlled traction machines do it as well as any method I have seen. But these machines are expensive and highly marketed devices that are owned and operated by M.D.'s and chiropractors. Try to strike a deal for the treatments if you choose them; there are a lot of options in most markets these days and prices are coming down (remember how much Lasik used to cost?). And don't get swept up by traction-machine infomercials. Traction is good, but not a miracle.
9. What About Postural Therapy?
Folks with a backache often believe that their bodies are somehow "out of alignment." Given how often a little twist or pull can suddenly make agonizing back pain disappear, people commonly think it's a posture problem that caused the bad back in the first place. Whether or not that's true, postural treatments appear to work in 50% to 60% of the back pain patients I see.
There are many practitioners who have written about and offer posture-based diagnosis and treatment, but the method that has been most thoroughly developed and widely used is Egoscue, which has been effective for quite a few of my patients. Egoscue therapies also intrinsically emphasize things you should do even after your pain goes away — to reduce undue back strain. The postural-theory industry being deeply entrenched, it should come as no surprise that postural therapies require a significant commitment of time, effort and, often, dollars to work.
10. Acupuncture and Massage
A 2007 study showed that acupuncture was much more effective than P.T. for backache — and that sham acupuncture was as effective as the real thing. Needles stuck into patients by a trained and licensed acupuncturist were just as likely to ease pain as needles put in random spots by untrained workers. Another study in 2009 found that poking people with toothpicks in standard acupuncture spots helped back patients just as much as using real acupuncture needles — and both treatments worked better than standard care.
What does this mean? That the benefits of acupuncture are likely at least partly attributable to the placebo effect. Not that there's anything wrong with that — but it's up to you whether you're a believer. The placebo effect appears to be stronger when the sham treatment is painful and invasive ("This has got to work — see how much it hurts!"), so dummy needles should work better than dummy pills. But given that acupuncture is quite safe, as long as needles are clean, if it appeals to you, you should try it.
Acupuncture hasn't made it to the mainstream yet, but in 2008, experts from the American College of Physicians and the American Pain Society did sanction it, recommending that clinicians consider acupuncture for the treatment of back pain in sufferers who don't respond to self-care.
Many patients also find massage pleasurable and helpful for a bad back. All the endorphins it releases are probably a natural pain reliever. But as with acupuncture, many insurance plans won't pay for massage — not even if you get your doctor to write a prescription for it. Still, many people say it's worth the money.
All of these are mostly imperfect choices for dealing with a backache, a problem that is often humbling for the patient and doctor alike — one that reminds us of the often limited value of science and reason in dealing with the painful aspects of our human condition
Read more: http://healthland.time.com/2011/04/25/10-tips-for-treating-back-pain/#ixzz1KdO3c1G7
If you're experiencing your first really bad backache, you're probably panicking a little about the pain and its implications — what if it's cancer? What if it never goes away? My first piece of advice is, relax. Low back pain is very common. About 80% of American adults will miss work at some point because of it. And most of the time, it's neither permanent nor serious: 95% of backaches go away within six weeks, with no specific treatment. Following are 10 essential things to know about dealing with a bad back.
By Dr. Scott Haig Monday, April 25, 2011
1. Prevent or Treat Spasm First
Being anxious or stressed out about back pain — or stressed out in general — will increase your chances of muscle spasm, which is itself both a source of back pain and an amplifier of other sources of pain. In addition to psychological stress, caffeine, dehydration, lack of sleep and low sodium are also likely to increase spasm and cramping.
What does spasm feel like? When you're bent over to one side and just can't straighten up, that's typically muscle spasm. The "stiff back" that hurts more than usual is also likely to be the result of spasm. Your first order of business should be rest and heat, but read on for some other clever physical maneuvers that can be effective for both back pain and muscle spasm.
2. Listen to Your Body
If you know it's going to hurt to try to move that refrigerator right now, don't do it. Your pain will not lessen or recede any faster if you ignore it and fight your way through. Forcing yourself to bend, twist or lift makes things worse.
Take it easy when your back hurts. Sit or sleep in the most comfortable position you can find. In most cases this means lying on your back with three or more pillows under your legs so that the hips and knees are both flexed 80 to 90 degrees.
Walking can be pretty painful early on, so avoid it at first. As the pain subsides and you straighten, going for a walk — with nothing in your hands, feet pointing straight, head up — is usually beneficial.
Listen for danger signals from your body as well. Electrical pains radiating down your legs; numbness or weakness in the lower extremities or crotch; or any loss of bowel or bladder control mean its time to seek out a doctor. If so, skip ahead to Tip No. 5, and make the phone call.
3. Rest & Exercise
Rest, anti-inflammatory pain medicines like ibuprofen (Advil), naproxen (Aleve) or acetaminophen (Tylenol), and a few days time will resolve many backaches. Applying heat or cold on the back relieves some patients' pain. In the hot-versus-cold debate, I've had an equal number of patients benefit from one but not the other. (Sorry, there is no official medical answer.)
Stretches and exercises to relieve low back pain — the kind you read about in self-help books and magazines — can be great or terrible, depending on the exercise and what's causing the pain. If you're doing this on your own, it makes sense to play the odds when it comes to these therapeutic maneuvers. For safety and effectiveness I can recommend only two: see Tip No. 4, next.
4. Stretches: The 90-90 and the Belly Hang
When it comes to stretches, my best advice for the most common, "generic" backache is the "90-90" position: lying on the floor with your calves flat on a chair or other horizontal surface, hips at 90 degrees to your body, knees flopped comfortably apart till you are not using any muscle force to stay there. The idea is to rest your spinal muscles and hip flexors completely. With the small of the back flat on the floor, thighs roughly vertical and calves horizontal, the back muscles that have been straining all day to prevent painful motion can relax. A tall person needs some flat cushions to make the chair higher, a shorter person needs a lower chair — like the seating surface of a couch. A sturdy box of just the right height, covered with a blanket works well too. Arms should rest comfortably out to the sides, head flat on the floor. Once you settle in and get relaxed, stay in that position for 15 minutes. This breaks spasm in some muscles, opens up the nerve spaces and evens out the forces across the small joints of spine. If it feels good and gives any relief the first time you try it, continue to do it three times a day.
The other reliable maneuver is a belly hang. Do this when you feel "crooked," or if the pain is radiating into your buttocks. Go down on hands and knees, straighten your elbows and rock forward till your shoulders are over your wrists. Hang your head down and just let your belly hang loosely, as far down as it will go. Stay there for five minutes. This is a lumbar-extension maneuver, sort of the opposite of the 90-90. It is good for breaking painful contraction and spasm in the spinal extensor muscles. Those "backstraps" — the muscles that extend or "bend back" the spine — get a strong signal to shut off when the spine is being bent back already, which is what happens when you do the belly hang. It may also help massage a bulging disc back into place.
5. Know When to Seek Help
a. Insurance. Your policy probably won't pay for massage, postural therapies or acupuncture. It might pay for some physical therapy, except with a huge enough co-pay that you'll end up basically paying for it yourself. You might also have a high deductible, which again increases your out-of-pocket cost.
Further, HMOs usually make you see an internist or family doctor before you see a therapist or specialist. That means you'll have to make an appointment with your primary care physician first, wait for that, then make an appointment with the physiatrist or orthopedist he or she recommends, and wait for that. (See how it works? You have a pretty good chance of getting better by yourself in that time.)
HMOs typically pay very little toward chiropractic care, which — apologies, colleagues — is often an excellent, efficient way to get rid of a backache.
b. Severity. If you are utterly debilitated by your back pain, you need to see a medical doctor who can prescribe drugs. However, it is not recommended to take narcotics for low back pain for a host of reasons, the most important of which is that the drugs can and usually will make the pain worse if you stay on them for more than a couple of weeks. But if you need drugs, you do need to see a physician — who I hope will have the sense to use every means possible to get you off painkillers as soon as possible.
c. Risk. Yes, some backaches are caused by things that can kill you: an aneurysm, cancer, spinal infection, even kidney problems can present as back pain. M.D.'s are trained to watch out for these.
What are the common signs that something rare and risky may be causing your backache? Ask yourself: is it the same old backache you get every time you shovel the walk? Probably not risky. Does the pain get worse at night in bed, boring in like a toothache? That could be cancer or an infection. Weight loss and fever along with the bad back are very bad signs too. Is the pain sudden and severe, ripping down your back or into the groin? It could be aneurysm or kidney stone. This last scenario is one of the few back pain emergencies — go straight to the emergency department with this.
6. Who Treats Back Pain?
There is no shortage of health-care providers who treat back pain. Below is a partial rundown of who does what.
Doctors are divided into M.D.'s, who graduated from a traditional medical school, and D.O.'s (doctor of osteopathic medicine), who have pretty similar educational backgrounds, except with training in "osteopathic manipulation," which can be a quick, easy and safe way to decrease your back pain. Problem is, most D.O.'s don't actually practice much osteopathy with manipulation. They are under the same rules and financial pressures as M.D.'s, so they're likely to do what most M.D.'s will do: write you a prescription and send you to see someone else.
Orthopedic surgeons end up seeing bad backs a lot and they will usually give you sound advice on what to do. Most of us don't really specialize in low back pain, however; our focus is on surgery of other joints.
There are both orthopedic and neurosurgeons who call themselves "spine surgeons," but curiously, few of these docs want to see patients with low back pain — at least not right off the bat. Many in my area will not even give an appointment to a patient unless he or she has already had an MRI, which means they have to have seen some other doctor first.
About 1 patient in 50 with a backache actually needs an operation, and you should not be thinking about spine surgery for your pain unless at least one, or better two, qualified doctors have recommended it. Unless you have already had a back operation in the past, you probably should call someone other than a spine surgeon when your back hurts.
Neurologists end up seeing a good bit of back pain. Of the docs who treat low backs, they are typically the most likely to use oral steroids, which can be effective — but there are some scary side effects. If the pain is greater in your legs than your back (a condition known as sciatica), or if you have numbness or weakness in your legs or feet, seeking a neurologist's care is a good bet.
A physiatrist is, overall, the most appropriate doc to see for back pain. Physiatrists do everything but operate, and their training is largely in what you need: the diagnosis and treatment of bad backs. They like to do spinal injections; they almost always order physical therapy; they often use oral medications. Physiatrists comprise a varied bunch however, so you would be wise to get a recommendation from a doctor who has previously referred patients with good results.
Generalists in medicine, like family practitioners, internists and emergency room doctors, see a lot of back pain patients. They can prescribe all the appropriate tests and medications as well as physical therapy — but they are not likely to direct your physical therapy like an orthopedist or physiatrist would (the good news is that physical therapists usually do a pretty good job of deciding your treatment on their own). General practitioners vary a lot in terms of how involved they get with a low back pain case, but the internist is my second pick (after physiatrist) for the doctor to see first with a backache.
7. Chiropractors Versus Physical Therapists
Chiropractors are called "doctor" — though many of us who have actually struggled through medical school bristle at this. Like M.D.'s, some are honest, some are crooks. Chiropractic theory itself is, well, a little smoky. But a chiropractor's manipulative treatments, if applied with an earnest desire to reduce pain, often provide relief (albeit temporarily) for backache. I have gone to a chiro myself on more than one occasion and his treatment definitely took the edge off my pain for the rest of the day.
Physical therapists have to complete four years of legitimate and pretty hard postgraduate study to put R.P.T. (registered physical therapist) after their names. In some states, you need a referral from a doctor to see a physical therapist; in others, you can go directly to a P.T. for diagnosis and treatment of back pain. P.T.'s use a wide range of treatments, but I have hardly ever seen them use chiropractic manipulations, even though they're qualified to do them.
All kinds of semi-scientific studies have been done comparing chiropractic treatments to physical therapy; my unscientific meta-analysis of these has the chiros ahead by a nose. But to whom do my colleagues in orthopedics and I send back-pain patients most frequently? To physical therapists. In fact, physical therapy is the most common treatment used for backaches in my practice, the payment issues mentioned in Tip. No. 5 notwthstanding. Why? Patient acceptance, and the fact that P.T.'s are much more consistent than chiros in how they treat.
8. What Is Traction?
Traction is a well-recognized and traditional form of physical treatment that helps many patients. It's not such an easy problem applying longitudinal force to a human's lower half; the spinal decompression DRX machine and other computer-controlled traction machines do it as well as any method I have seen. But these machines are expensive and highly marketed devices that are owned and operated by M.D.'s and chiropractors. Try to strike a deal for the treatments if you choose them; there are a lot of options in most markets these days and prices are coming down (remember how much Lasik used to cost?). And don't get swept up by traction-machine infomercials. Traction is good, but not a miracle.
9. What About Postural Therapy?
Folks with a backache often believe that their bodies are somehow "out of alignment." Given how often a little twist or pull can suddenly make agonizing back pain disappear, people commonly think it's a posture problem that caused the bad back in the first place. Whether or not that's true, postural treatments appear to work in 50% to 60% of the back pain patients I see.
There are many practitioners who have written about and offer posture-based diagnosis and treatment, but the method that has been most thoroughly developed and widely used is Egoscue, which has been effective for quite a few of my patients. Egoscue therapies also intrinsically emphasize things you should do even after your pain goes away — to reduce undue back strain. The postural-theory industry being deeply entrenched, it should come as no surprise that postural therapies require a significant commitment of time, effort and, often, dollars to work.
10. Acupuncture and Massage
A 2007 study showed that acupuncture was much more effective than P.T. for backache — and that sham acupuncture was as effective as the real thing. Needles stuck into patients by a trained and licensed acupuncturist were just as likely to ease pain as needles put in random spots by untrained workers. Another study in 2009 found that poking people with toothpicks in standard acupuncture spots helped back patients just as much as using real acupuncture needles — and both treatments worked better than standard care.
What does this mean? That the benefits of acupuncture are likely at least partly attributable to the placebo effect. Not that there's anything wrong with that — but it's up to you whether you're a believer. The placebo effect appears to be stronger when the sham treatment is painful and invasive ("This has got to work — see how much it hurts!"), so dummy needles should work better than dummy pills. But given that acupuncture is quite safe, as long as needles are clean, if it appeals to you, you should try it.
Acupuncture hasn't made it to the mainstream yet, but in 2008, experts from the American College of Physicians and the American Pain Society did sanction it, recommending that clinicians consider acupuncture for the treatment of back pain in sufferers who don't respond to self-care.
Many patients also find massage pleasurable and helpful for a bad back. All the endorphins it releases are probably a natural pain reliever. But as with acupuncture, many insurance plans won't pay for massage — not even if you get your doctor to write a prescription for it. Still, many people say it's worth the money.
All of these are mostly imperfect choices for dealing with a backache, a problem that is often humbling for the patient and doctor alike — one that reminds us of the often limited value of science and reason in dealing with the painful aspects of our human condition
Read more: http://healthland.time.com/2011/04/25/10-tips-for-treating-back-pain/#ixzz1KdO3c1G7
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