An Integrative Approach to Back Pain

Timothy B. McCall, M.D.

Nearly everyone experiences low back pain at one time or another. Current estimates rate back problems as the second most common cause people consult MDs, the top reason for visiting a chiropractor and the leading cause of disability of people under 45. The most common malady is referred to as low back strain--a catch-all phrase that includes minor muscle, ligament and joint problems in the lumbar spine and surrounding tissues. In more severe cases, low back strain progresses to sciatica, a condition in which the shock-absorbing disk that separates two spinal vertebrae bulges out and compresses the nearby root of the sciatic nerve. Less commonly, low back pain can be a sign of a more serious medical condition (see More Serious Causes of Back Pain).

The new thinking about treating lower back problems emphasizes a more active approach than what most conventional physicians recommended until recently. For years standard medical therapy was three to seven days of strict bed rest. Those recommendations have been changing since a 1995 study in the New England Journal of Medicine found that bed rest actually slowed recovery: Patients who continued their ordinary activities (within the limits permitted by their pain) were symptom-free and back on the job sooner. A possible explanation is that lying in bed for days deconditions back and abdominal muscles enough that it counteracts much of the benefit of resting the spine.

For an example of a more active approach, consider the story of Christopher Morey, a 45 year old computer network administrator from Traverse City, Michigan. Morey says he’d “always had a bad back.” His usual discomfort had been getting worse for about six months when, while carrying out a not-terribly-heavy garbage bag, he noted a sudden, excruciating pain in his lower back which shot all the way down to his foot—a classic symptom of sciatica. Following the guidance of Richard Miller, a yoga therapist and teacher, within a day of injuring himself, Morey began a regimen of gentle yoga poses designed to help his back.

Meanwhile, Morey’s primary care doctor ordered an MRI scan, then referred him to a neurosurgeon. That doctor—chosen because he had the reputation of not recommending back surgery too often--took one look at the giant bulging herniated disk on Morey’s MRI and chuckled. “If it was half this size, I’d still want to operate.” What he proposed was a “mini diskectomy,” an operation in which the herniated disk is removed though a one inch incision in the back. By that time, however, Morey was already starting to feel a little better and decided to stick with the yoga and see what happened.

Studies show that most people get over an episode of acute back strain using any one of a variety of treatment modalities. Physical Therapy (PT) early in the process also appears to be beneficial. A study published in the January 2000 issue of the Journal of Occupational and Environmental Medicine found that the speediest recoveries were made by back pain sufferers who began PT the day of the injury or the day after. People who began two to seven days later did better than those who started PT the following week.

Also useful in getting through an acute episode are such hands-on approaches as massage, chiropractic and osteopathy (though not all osteopaths do spinal manipulation so ask before making an appointment). The evidence on acupuncture is mixed but since its very safe it may be worth a shot. Medication can be useful in relieving symptoms. Doctors commonly recommend anti-inflammatory pain-relievers like aspirin or ibuprofen (Motrin, Advil, etc.) but these drugs can cause stomach upset and intestinal bleeding. Acetaminophen (Tylenol, etc.) also can relieve pain and, when taken in recommended doses, is much safer. Herbal remedies such as willow bark tea (which contains the active ingredient of aspirin) and topical creams containing red pepper (capsaicin) or arnica can also bring relief. Liniments based on methyl-salicylate, menthol and camphor are soothing and very safe. Many people find applications of ice helpful and, once the injury is starting to heal, switch to moist heat either alone or alternated with ice.

These treatments can all help you through a bout of acute backache. The problem is that they may not lead to the kind of long-term changes that are likely to keep back troubles at bay. That’s why it’s important to understand what sets you up for back pain in the first place, how factors like posture and your work and living environment affect your back’s health and what you can do to change what might seem inevitable.

A Long-Term Prevention Strategy