Explore the common but under treated and misunderstood issues that accompany chronic back pain in our Back Pain Series. Part 1 explains the latest treatments that could relieve that aching back.
By Denise Mann
Reviewed By Brunilda Nazario
Many Penn State alumni fondly remember David K., now 34, as the student who crawled to class. Mired by back pain throughout his four years of college, David saw tons of doctors from top neurosurgeons to psychologists for the pain. Instead of listening to the popular college music of his day like REM, he listened to the soothing sounds of pain expert John E. Sarno, MD, on cassette tapes called Mind Over Back Pain when he drove his Mustang around the college campus.
"If you don't have chronic back pain, you can't possibly imagine what it feels like," he says. "It's unbearable -- literally." He says that there were many times he couldn't walk and would have to crawl from his fraternity house all the way to class so he would not miss a midterm or final exam. "My fraternity brothers made a lot of fun of me," he says. "Still do."
About 80% of Americans -- or four in five -- experience low back pain at some point in their lives and understand David's plight all too well. Many people with chronic low back pain are working age and for them, back pain is the most frequent case of lost productivity. Treatment for back pain costs roughly $100 billion a year, according to the American Academy of Orthopaedic Surgeons in Rosemont, Ill.
But new developments may signify hope, help, and healing for millions of back pain sufferers including David K., my husband.
First Things First
Without exception, the first step for people with back pain is to "[get] a good history and try to establish the onset and aggravating factors," says Joel R. Saper, MD, director of Michigan Head Pain and Neurological Institute in Ann Arbor, Mich.
"A big mistake is to see a back pain problem in a narrow perspective," he says. "Doctors have to know the overall health, past experience with any pain syndrome, what precipitated it and what it has responded to at this point, and do a proper examination of the back and a general medical examination," he says.
Your best bet is to seek treatment from a "comprehensive program that specializes in pain with a wide range of services available so that treatment is determined by what you need -- not by what's available," he says.
"If you have back pain that lasts six weeks or more, seeing a specialist is a reasonable thing to do and the main reason is to make sure it's not a more serious condition that presents as back pain such as infection, tumor, fracture, or aortic aneurysm," says Scott D. Boden, MD, an orthopaedic surgeon and director of The Emory Orthopaedics and Spine Center in Atlanta.
For mild to moderate symptoms, over-the-counter painkillers such as acetaminophen, aspirin, or ibuprofen can help along with heat or cold applied to the back. Massage, acupuncture, and chiropractic treatment may also play a role for some people. Adjusting or modifying your activities may help; light activity may actually speed recovery.
Not for David. He has tried just about every medication and every alternative treatment for back pain, and nothing really did the trick for long. The new thinking is that "chronic back pain may be chemical and that's why some of the older treatments don't work," Saper explains. "There may be a chemical basis for sustaining the pain."
That said, there may be a role for treatments such as the tumor necrosis factor-alpha (TNF-alpha) blockers used to treat joint inflammation caused by rheumatoid arthritis. These medications, also known as biological response modifiers, neutralize specific chemicals that are key players in the inflammatory process.
Richard D. Guyer, MD, spine surgeon at the Texas Back Institute in Plano, says different types of drugs like seizure medications including Topamax and Neurontin may help relieve pain. "They are not for everybody, but they may have a role for people with previous spinal surgery and chronic leg or arm pain," he says.
Spinal cord stimulators can be implanted in the spine to help both back and leg pain, but they are better for leg pain, Guyer says. These medical devices work by sending low levels of electric stimulation to the spine to block the sensation of pain.
Also promising, but not yet FDA-approved for low back pain, is the lidocaine patch, says Charles E. Argoff, MD, director of the Cohn Pain Management Program of North Shore University Hospital in Manhasset, N.Y., and an assistant professor of neurology at New York University in New York City.
The lidocaine patch is worn on the skin like a bandage.
"It is a very simple, safe, topical analgesic and you can't hurt anyone with it," Argoff says, "In preliminary, non-randomized studies, it has shown great promise in treating both postsurgical low back pain and nonsurgical back pain."
The Opioid Dilemma
Opioid analgesics are one type of pain reliever and they do not work for everybody, says Argoff.
Opioids often get a bad rap from media reports of addiction such as recent reports of talk show host Rush Limbaugh's abuse. Buts some experts in pain management argue that fear of addiction to these medications has lead to undertreatment of patients with chronic pain.
The first question that needs to be answered is do they work for this patient, Argoff says.
If we get past that and show there is benefit, doctors need to determine whether this patient is at-risk of becoming addicted, he explains.
"There is no shred of evidence that suggests the acquisition of drug addiction, but not every patient walks into doctor office and says, 'by the way, before you prescribe, I am a drug addict' or 'I have an addictive personality,' and we can't as health-care providers already know who has that risk," he says.
"Very few people not known to be abusers become abusers, but frequent follow-up, medication contracts, and multidiscipline therapies can help prevent addiction and/or abuse," he says.
Botox, the same toxin that doctors routinely use to eradicate fine lines and wrinkles, can also treat back pain, says Gary Starkman, MD, a clinical attending neurologist at Beth Israel Deaconess Medical Center and the medical director of New York Neurology Associates, both in New York City.
"I use Botox for selected patients with back pain when I suspect muscle spasm is involved," he says. In cases of low back pain, Botox is usually injected into the muscles on either side of the spine in the area of pain.
"The results could last three or more months " he says, "but the pain relief is individual, and if it breaks the pain cycle, pain can go away for many months or completely." The only downside is the cost.
Botox may relieve low back pain because it relaxes the back muscles, but Saper says it may alter various chemical pain mechanisms that have nothing to do with muscles.
No Pain, No Gain?
"We now recognize that with simple back strain (such as when you wake up with a backache), we want you to remain active rather than take to bed," Saper says. "We used to put people to bed; now we get them out of bed."
This is why a growing number of doctors including Brain W. Nelson, MD, an orthopedic surgeon and medical director of Physician's Neck and Back Clinic in Minneapolis, are recommending exercise programs to people with chronic back pain. Such programs are aimed at strengthening the back muscles, and often patients see results in about nine weeks, he says.
"There is a growing movement towards fitness as an approach to chronic back pain," Nelson says. "I've come to believe that this is the way to go for the vast majority of people with back pain [and] I think that 10 years from now, it will be the mainstay of treatment because it is so dramatically more cost-effective."
Nelson points out that we are spending $100 billion a year on spine care in the U.S. and we do 10 times more surgery than any other industrialized country. "A single epidural [shot in the back to numb the area] costs $1,500. That's almost the cost of our entire program," he says.
Just as David K. crawled to class, "people become experts at protecting their back and learn to do activities without using it to protect it, but you pay a price -- you essentially lose a lot of functional ability with the part of body that you are trying to protect," he says. "Your back is becoming more fragile [but] aggressive physical strengthening can increase the capacity of your back and you typically will have a very significant decrease in pain," he explains.
"A key part is putting people in positions and using special equipment that does not allow them to cheat and forces them to move a body part that they don't feel like moving -- their back," he says. This is for people with chronic back pain, not acute injuries, he stresses.
"Our goal is to make sure they are better a year from now, five years from now, and 10 years from now, and the only way to do that is to aggressively strengthen the back and show them how to maintain it," he says.
"If you read this article and say, 'this makes sense to me,' look around your community and call some places and say, 'I am looking for a fitness approach to back pain," he suggests.
Guyer says, "People that get into active strengthening exercises really do the best because they also get a release of endorphins to control the pain," he says. Endorphins are considered the body's own "feel-good" or "pain-killing" chemicals and are known to be released with exercise.
The Changing Face of Spinal Surgery
Only a small percentage of patients with back pain are candidates for surgery, but for these patients, advances in techniques have made recovery a much easier road, says Boden of The Emory Orthopaedics and Spine Center.
Fifty years ago, a spine fusion meant a two-week hospital stay, a body cast or brace for months, and a minimum of six months away from normal activities. A spinal fusion is performed by fusing the vertebrae together with bone grafts to eliminate motion between two adjacent vertebrae where motion is causing lower back pain.
Today, minimally invasively techniques allow for smaller incisions, less blood loss, and faster recovery time, Boden says. Some spine fusion techniques can be done on an outpatient basis.
Fifty years from now, Boden predicts that disc replacement will be an alternative to spinal fusion. Moreover, gene therapy will be able to prevent or reverse disc degeneration, and genetic research will help discover genetic sources of back pain, he says.
"Gene therapy for disc regeneration may be more than five years off, but less than 20," he predicts.
Published July 6, 2004.
SOURCES: Joel R. Saper, MD, director, Michigan Head Pain and Neurological Institute, Ann Arbor. Gary Starkman, MD, neurologist, Beth Israel Deaconess Medical Center; medical director, New York Neurology Associates, both in New York City. Scott D. Boden, MD, orthopaedic surgeon; director, The Emory Orthopaedics and Spine Center, Atlanta; Brain W. Nelson, orthopedic surgeon; medical director, Physician's Neck and Back Clinic, Minneapolis. Richard D. Guyer, MD, spine surgeon, Texas Back Institute, Plano. Charles E. Argoff, MD, director, Cohn Pain Management Program of North Shore University Hospital, Manhasset, N.Y.; assistant professor of neurology, New York University, New York City.
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