Back Pain Treatment

Back pain is extremely common and in most cases is not a serious medical matter. Back pain causes are numerous but the most frequent type of back pain is called non-specific lower back pain. This means that the cause of the back pain may not be clear as back pain diagnosis is very far from being an exact science but is presumed to be a sprain or strain of a muscle, ligament, disc or joint in the spine. Back pain symptoms such as the pain can be very severe and disabling or mild and quickly easing. In troublesome cases the pain may recur and even develop into a chronic or long-term pain problem.

Back or spinal pain can occur in various areas of the spine, including neck pain, upper back pain and middle back pain as well as low back pain. Referred pain from the spine can mimic shoulder pain or kidney pain. Sciatica is rarer at around 5% of back pain sufferers and is caused by a disc prolapse most commonly, while the causes of back pain are much less clear.

Upper back pain causes and middle back pain causes may be clearer than the causes of low back pain. Upper back pain is often related to neck problems and mid back pain to joint and postural difficulties. People often ask about right side back pain causes or lower left back pain causes and this likely is due to the changes occurring in the spine being greater on one side or another, so the lower right back pain causes would be related to joint, ligament or disc changes on the right side of the lowest lumbar segments.

Good resources for back pain treatment are available at NHS Choices and at Patient UK.

Low Back Pain Treatment

The best lower back pain treatment for managing acute pain is self care and medication.

Medication

Talk to your doctor or pharmacist if you have any queries about taking medication for your back pain.

Paracetamol

This is recommended as the first drug to take for back pain. It is important not to take more than the stated dose and not to mix it with other drugs which may also contain paracetamol.

Non-steroidal anti-inflammatory drugs (NSAIDS)

The most common version of this kind of drug is ibuprofen and this can be added if paracetamol is not sufficient. However there are risks and side effects of taking these drugs including indigestion and the development of stomach ulcers and bleeding.

The Cox-2 inhibitor type of NSAIDs are often prescribed to reduced the negative effects on the stomach lining but have been shown to increase the likelihood of heart attacks in people with a history of these problems. Discuss this with your doctor.

Codeine and Tramadol

These milder opiate painkillers can also be added to control pain but may not give much of an added effect and can carry a lot of side effects such as nausea, drowsiness and a dry mouth. This may limit driving or operating machinery.

Strong Opiate Painkillers

The stronger opiates such as morphine, MST and many other combinations are only used in cases where the pain is very severe although patients with chronic back pain may take them for long periods. There is a potential for addiction although this is low for people taking them for pain problems. However you should not stop taking these drugs suddenly without advice as you may suffer badly from both increased pain and withdrawal. Again, nausea may be a problem, along with constipation and drowsiness.

To counteract the effects of some of these painkilling drugs the doctor may give you more such as medication to treat your nausea and constipation.

Diazepam or Valium

This drug is used as a muscle relaxant in cases where acute back muscle spasms are an issue as they are in some people. It is used carefully as it is very addictive and people should not drive or operate machinery whilst on this drug.

Self Management of Back Pain

• Don't panic! Even though it feels terrible, acute back pain is not a sign of something seriously wrong with you or your back. Keeping a positive mental attitude has been linked with a quicker recovery from back pain and a reduced likelihood of developing a chronic back pain problem.

• Keep up activities as normally as you can. If the pain in severe you may need to limit your activity greatly or even rest completely for a day or so, but as soon as you can you should get back to normal day to day tasks, returning to full and normal function. Don't wait until all the pain is gone before going back to work or your normal daily routine.

• Whilst avoiding a severe worsening of your pain, you should challenge your back gently every day by setting goals for activity such as being up for a number of minutes every hour or walking to the paper shop daily. Do more each day.

• Sleep as you can most comfortably. Orthopaedic and firm mattresses are not necessary and there is no evidence which shows they are helpful to back pain sufferers. You will need to know which type of bed suits you. When on your back you could have two or more pillows under you knees and if on your side a pillow between your knees. This may reduce the stresses on your back and allow you to rest more comfortably.

• Go back to work as soon as you can, it will not be damaging to your back and having some pain whilst back at work is not a significant concern. Keeping busy can distract you from the pain and get you back to normality sooner.

• Avoid resting for significant periods, which was often advised in the past. However, modern research shows this is a counter-productive strategy and can make the development of chronic low er back pain more likely.

• Take painkillers regularly as advised by your doctor, do not take them just when the pain is severe. It's better to take them as full doses for a while as this will allow you to be more active and return to normal more quickly.

• Physiotherapy may provide some back pain relief if you have problems with joint restriction as well as pain, with physios teaching mobilising exercises and core stability work.
  
  

The prognosis (how things are going to go) for low back pain is generally very positive. Whilst many people will have a good easing of their back pain within a week it has been shown that a significant section of people still have some problems after a year. Recurrences of back pain are also common, particularly during the first year after the initial episode, and if they are numerous and lead to more persistent problems, chronic back pain is what results. This is a different matter to acute back pain and needs different management.

Preventing Further Back Pain Episodes

Keeping active and exercising regularly have been indicated as the important things in preventing further episodes of acute back pain. Other exercise regimes may be useful but the evidence is not clear. Pacing activity (spreading jobs out over time) and the avoidance of performing jobs in awkward positions are obvious common sense strategies.

References – Acute Back Pain

The Back Book: the Best Way to Deal with Back Pain; Get Back Active

Royal College of General Practitioners, The Stationery Office, 2002. Around £1.25 from Amazon.

This 21 page booklet summarises the scientific evidence for the management of acute back pain episodes and is written by a combination of professions including a physiotherapist, osteopath, orthopaedic surgeon, psychologist and GP.

Chronic Back Pain

Back pain is said to be chronic if it occurs on most days over a period of more than three months (or six weeks in some opinions). It is very common to have mild or recurrent chronic back pain problems as many acute episodes do not settle completely or happen again within the first year after the initial event.

However in 5-7% of back pain sufferers chronic back pain becomes a much bigger problem and leads to high pain levels, significant disability, work loss, depression and loss of income and self esteem. Treatments for chronic back pain are not simple and are aimed at helping the person become more active and able whilst coping better with their pain problem.

NICE guidelines in the UK were published in 2009 for treatments for chronic back pain but these have not met with universal agreement.

The Chronic Back Pain Treatment Plan (according to NICE)

NICE has recommended painkilling drugs plus another treatment option which could include:

• Manual therapy which involves a physio or other therapist massaging or manipulating your back and giving exercises and advice.

• Exercise classes such as gym work for muscle strengthening with stretching and aerobic exercise such as swimming, jogging, treadmill work or cycling.

• Acupuncture where very fine needles are inserted shallowly into the skin at various particular points over the body.

Should these treatments not be effective in relieving a great proportion of your back pain the suggestion is to attend a programme which combines exercise, pain management techniques and psychological treatment. These mostly occur in or allied to pain management programmes.

In severe cases where the quality of a person's life is unacceptably low and they have tried other treatments, referral to a spinal surgeon for consideration of spinal fusion may be appropriate.

Painkillers

The “analgesic ladder” is the recommended approach for taking these drugs, i.e. you step up gradually to the next level if you need to and only then. Taking the minimum number of drugs at the minimum dosage for best effect is the aim due to the number of side effects which they can generate.

Paracetamol is the first line of treatment but most people with chronic back pain find it is not strong enough on its own but useful when combined with an anti-inflammatory drugs and sometimes with a mild to moderate opiate drug such as the codeine based drugs. Stronger opiates are used to manage long term back pain but this may be best achieved under the supervision of a pain management consultant.

Other drugs which may be trialled for troublesome chronic back pain are a group called the tricyclic antidepressant drugs. Whilst these medications were initially designed to treat depression they have been found to be useful in managing some types of pain problems. Amitriptyline is the commonest drug used here.

If amitriptyline is not very effective then there are other drugs which can be tried such as gabapentin (originally for epilepsy) and pregabalin or Lyrica which was designed for pain treatment. These are often trialled in pain clinics and reduced and stopped if there is not a good effect.

You should stick closely to the advice you are given and the drug leaflet instructions if you are taking any of these drugs.

Acupuncture

Acupuncture is part of traditional Chinese medication in which fine needles are inserted into the skin at specific points on the body. The underlying Chinese philosophy is hard to make sense of in Western terms as it has to do with energy channels in the body and blockages or otherwise of these.

However there is some evidence that acupuncture does change pain symptoms and the reasons are suggested to be to do with the release of the body's own painkilling substances (called endorphins) by the needle insertion. Western acupuncture, often practised by physiotherapists and other therapists, is based on this idea and NICE recommends a total of 10 sessions over a twelve week treatment period.

Acupuncture is not wholly without side effects although they tend to be mild and occur in about one in ten cases, including increase in the pain symptoms, tiredness, bleeding or bruising at the needle puncture points and pain over the insertion points too.

NHS provision of acupuncture is variable as it mainly depends on physiotherapists who have undergone the required training which is expensive and the various training bodies increasingly demand repeat courses to maintain certification which are also expensive.

Exercise Classes

There is good evidence that exercise helps people with back pain to become more active and cope better with their pain. If prescribed these classes you may be offered eight sessions over the twelve week training period which will involve groups of about ten people being supervised by an exercise instructor.

The exercise types will typically include aerobic work to stimulate the heart rate and increase the metabolic rate such as cycling, swimming or treadmill work, muscle strengthening and stretching. It is important to attend regularly and to keep up the exercise in the longer term as it is then that the benefits really begin to show themselves.

Manual Therapy

In the UK physiotherapists are the main providers of manual therapy although osteopaths and chiropractors are also represented in smaller numbers. Again a treatment programme of eight sessions over twelve weeks may be suggested.

Manual therapy falls into three different techniques

• Massage

• Spinal mobilisations. These are repeated passive (i.e. the physio does them to you) movements which work within the normal ranges of your joints. They may be very gentle or quite vigorous and may be uncomfortable during their performance.

• Spinal manipulation. This is a sudden force applied to a joint to push it beyond its present range of movement in order to restore lost movement and reduce pain. There are risks with this treatment (especially for neck manipulation) but all therapists should be trained and aware of them.

Physiotherapy, osteopathy and chiropractic use basically a similar approach to musculoskeletal problems. There is an assessment of the pain, loss of movement, weakness or stiffness of the various components of the spinal area, then a treatment is applied to improve this with exercises often suggested to strengthen muscles or stretch out tight structures. Different techniques are used but the similarities outweigh the variations.

Physiotherapy is closely allied to the medical model but physios are independent practitioners and rely on evidence based treatment as far as possible even though they treat patients with many techniques for which good evidence is not forthcoming.

Osteopathy and chiropractic are classified as complementary or alternative medicine (CAM) practices as they have their own models of disease and illness.

Combination Therapy

This relies on a pain management approach which is that pain and disability are not just physical problems but also have psychological and social aspects. You may be selected for this kind of therapy for two main reasons:

• You have not improved with one of the treatments mentioned already.

• Your back pain is significantly affecting your ability manage your activities of daily living, going to work and is generating significant distress.

CBT or cognitive behavioural therapy is a technique used to manage many kinds of pain, disability and mental problems and is based on the idea that what you think and feel about your situation has a significant bearing on how you experience your pain, your outlook on life and what you decide to do about it.

Research work has indicated this kind of training has positive effects which are maintained over time, including increased activity, exercise compliance and a more realistic and less negative attitude to their situation.

Spinal Fusion Surgery

Spinal surgeons have a limited range of options to manage chronic back pain and most people are not offered an operation. A small proportion may fit the criteria for surgical intervention and be offered spinal fusion or disc replacement.

To be eligible for spinal fusion you must have:

• Tried the therapy routes including pain management.

• Severe and continuous back pain.

• Objective signs of degenerative disc disease on MRI scanning, confined to one or two discs. If you have spinal stenosis or a tumour then surgery is more straightforward in terms of the decision to proceed.

• A willingness to accept the risks of major and irreversible surgery.

The aim of spinal fusion is to remove the painful “segment” which typically means the disc which is worst affected and place a bone graft in this space to keep the alignment. When this fuses the two vertebrae are now one unit and the joint between them has been abolished. The disc itself may have been a source of pain, and loss of disc height can have negative and painful effects on the nearby facet joints and the nerves which exit nearby.

Problems with spinal fusion do occur and even in good outcomes people need to recognise that they are not fully restored and should take some care in their activities to maintain their pain-reduced status, as complete pain relief may not be that common.

Major complications include:

• The pain is not significantly reduced, which occurs in about one in five operations, often for reasons which are not clear.

• The fusion does not take, i.e. the vertebrae do not fuse together as planned, which occurs in about five to ten percent of this operation type.

Other Back Pain Treatments

There are a huge number of treatments focused on treating back pain and all other types of pain, most of which have no evidence to support their claims and are usually a way of making money for the person or organisation promoting them.

In terms of physiotherapy treatments, techniques used without much evidence of usefulness include laser therapy, ultrasound, traction, interferential therapy and corsets.

Information-back pain has the current self management of low back pain set out in abbreviated form and a back pain blog can be helpful in understanding what 's going on as it comes from someone who has had genuine first hand experience of back pain and its management.