Principles of Treatment for Low Back Pain
Dr. Jerry Sobel at Sobel Spine and Sports in Phoenix, Arizona believes the goal of treatment is to improve the function and quality of life for our patients whether they suffer from low back or neck pain, sciatica, arthritis, chronic pain, or a sports related injury. Treating any type of low back condition or joint pain requires a knowledge of the natural history of the condition. In other words, what would be the natural course of say acute low back pain or shoulder pain if left untreated? Do people just get better or does the pain and loss of function linger on for months or years? It is through this understanding that Dr. Sobel is able to determine the best course of treatment for these types of problems. Let’s look at low back pain as a good example.Low back pain (LBP) affects 80% of the population with 10 million people per day missing work because of pain. It is estimated that at any given point in time 15-30% of people have low back pain, over a one month period 19-43%, and during a lifetime 60-70% have suffered from back pain. The medical literature suggests that the overall picture of low back pain is that it is a recurrent and intermittent problem. It is only a small minority that develop chronic back pain. Lower back pain, therefore is truly a common medical problem that affects most people at some point or another in their lives and for the majority will be a recurrent issue. This is a very general view and it is accepted that some people will not follow this pattern and rarely have more than a twinge of pain and others will suffer with severe disabling symptoms for years.The good news is that for most the pain will be mild.Sciatica pain or leg pain originating from the low back is considered separately because in the general population is it far less common than back pain alone. It is estimated that in a lifetime only about 2-5% of people develop this problem.
The treatments of acute and chronic low back pain are very different. In acute back pain, the focus is on making sure that the patient does not have a serious medical problem causing their pain. Serious being such things as fractures, infections, tumors and autoimmune disorders, e.g. rheumatoid arthritis, ankylosing spondylitis. Fortunately, only a very small number of people that seek out a doctor for low back pain have one of these conditions. The overwhelming majority have what is referred to as non-specific low back pain. It is called this because more often than not the specific cause of pain cannot be found. Today, even with all of the state of the art diagnostic methods that clinicians have at their disposal, often times the pain management doctor is incapable of reliably identifying the exact cause of the pain.
This excludes those patients that have low back pain with or without numbness and/or weakness that radiates into one or both of their legs. This is known as radiculopathy or sciatica. This is evaluated and treated differently then patients with back pain only. Many of these patients can benefit greatly from epidurals or selective nerve root blocks to reduce the inflammation of the pinched nerve.
So, you want is the best course of treatment for recent onset low back pain. This has been studied extensively in the pain management literature and it has been found that many of the common treatments used for acute back pain really do not influence the recovery from pain and loss of function. This fact may be very surprising to a number of people. Medical journals are filled with studies that show that for the most part, individuals with acute low back pain will improve regardless of what type of medication or treatments are prescribed by doctors and therapists.
This is however, not the case with chronic low back pain as some forms of treatment can be very effective in reducing pain and allowing sufferers to return to productive and enjoyable lives once again. The treatment of chronic pain requires a comprehensive evaluation to determine if a readily identifiable source of pain is present. Often times this is done with MRI’s, EMGs and the use of selective spinal injections such as selective nerve root blocks, facet joint and medial branch injections. Ultimately, the goal of care in a person suffering from chronic low back pain is to increase function, reduce disability and improve the quality of life even if the pain does not go away. This usually requires a multidisciplinary therapy program that uses physical and sometimes occupational therapists, psychologists, vocational counselors and social workers. Exercises for back pain are a critical component of any rehabilitation program. Without stretching, strengthening and cardiovascular endurance training little progress in improving function will occur. Dr. Jerry Sobel of Sobel Spine and Sports has an extensive research background and clinical experience in physical reconditioning of those patients with chronic low back and neck pain. This reconditioning process is a key component of pain management.
With respect to acute low back pain, primary care, orthopedic and pain management doctors are turning toward treatment guidelines to help them determine what is the most effective form of care for back pain. Development of these guidelines is based on the best available research in a particular field and is written by experts. Since 1994, 10 countries have published guidelines for the treatment of pain in the low back (USA, Netherlands, Israel, New Zealand, Finland, Australia, UK, Switzerland, Germany, Denmark, Sweden). Recommendations for the treatment of recent onset low back pain are reasonably consistent across countries. Specific recommendations include:
- Patients are to be advised to stay active and continue normal activities including work if possible, instead of passive interventions.
- Bed rest is discouraged, and suggested only if the pain is severe, and then only for a couple of days.
- Pain control is essential to allow people to return to normal activity.
- First choice of all guidelines is simple pain relievers like Acetaminophen. The use of non-steroidal anti-inflammatory drugs, (NSAID’s), such as Ibuprofen and Naproxen are recommended if acetaminophen is not effective.
- If these fail, then consider a muscle relaxant for a short period of time (2 weeks) either on its own or with an NSAID.
- Narcotics are inconsistently recommended.
- Recommendations for back-specific exercises varied from country to country. Some considered they were not useful (Dutch and UK). The US guidelines suggest low stress aerobic exercises.
- Those guidelines that included the treatment of chronic LBP consistently recommended exercise therapy.
- Recommendations for the use of manipulation was considered to be a viable option in the acute setting.
In conclusion, the overwhelming majority of people with acute low back pain improve and return to normal functioning. It is important to stay active, continue with normal activities and to minimize bed rest. In the long run, exercise is the the single best treatment for recurrent back pain.
Dr. Jerry Sobel is a board certified physical medicine doctor that proudly serves patients from Phoenix, Scottsdale, Mesa, Chandler and Glendale.