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I Hurt My Back...What Now?
I imagine that many people reading this article right now have seen at least one advertisement for the next “quick fix” for back pain. Back pain can be a debilitating scenario for anyone and is the second most common reason why people go to the doctor. It is also one of the top complaints for why people are unable to work. In a recent study factoring in costs of care and costs to employers, the annual cost of back pain in America is over 193 billion dollars. As you can now imagine, back pain can mean big business for healthcare providers but big losses for business who lose employees and therefore productivity.
With so many treatment methods, so much new technology and different approaches to medicine, it is easy for a patient to have a vast amount of information before them in which they must make a decision about. And unfortunately, it is easy for a patient to sometimes get caught up in treatment options that may have weak scientific evidence -- treatments that may have a heavy price tag without the benefit of better health. The goal of this article is to touch on common and proven treatments for low back pain and hopefully help guide patients to the best and most efficient way to treat this ever-so-common complaint.
Imagine waking up one morning and you cannot move. You have “thrown your back out.” This is often how most people encounter their first episode of back pain. Many people think there must be a physical occurrence such as an injury or fall, lifting something heavy at work, or twisting the wrong way to instigate back pain. However, traumatic injury to the spine is not the most common scenario. Most back pain comes on gradually over time. It is estimated that 70-80% of people will suffer from moderate to severe back pain at least once in their life, so it is likely that at least once in your lifetime, it will happen to you. But if you do suffer back pain personally, there is no need to panic. Research shows us that typically, your body will get better. Over time, most people suffering from back pain will get better without physician intervention, but that may take a long time. And unfortunately, in today’s world most of us do not have the luxury of the time that may be needed for our bodies to heal on their own.
The first step in helping your body heal is to simply “get moving.” But this is not always as easy as it sounds. The impulse reaction is to stay in bed and rest until the pain goes away. But research tells us that no more than two days of bed rest is recommended for acute back pain. I usually recommend bed rest to my patients, but only at a minimum. The sooner one gets on their feet, the faster recovery can begin. At this point, anti-inflammatories (ibuprofen, Naprosyn, diclofenac) and acetaminophen (Tylenol) can also help patients manage the pain. A visit to your physician now may not do much for you other than provide a prescription for an anti-inflammatory or perhaps a muscle relaxant. These drugs may not be any more effective for you than what you can try over the counter first. There are, however, a few reasons a trip to the doctor may be advised at this point. If you experience weakness of the legs, incontinence of bowel or bladder, or intractable pain that does not respond to over the counter medications, you may need to contact your physician. And for some employers, a note from a physician is needed for excused absences from work. In that event, you may also need to contact them early on in your treatment.
As previously mentioned, most acute episodes of back pain resolve on their own. Over time, however, seeking care from a Chiropractor, Physical Therapist, or even Massage Therapist can be helpful. A surprising statistic in recent studies showed that of all healthcare providers that people could choose from for back pain, the majority felt that a chiropractor would be the most logical first step to alleviating their pain. As a physician, this tells me that patients prefer a conservative approach to their medical care without medications or surgery. As a Physiatrist and pain specialist, I support this idea completely. The conservative options are always best to consider first. Like with physicians, there are many chiropractic or physical therapists to choose from, and it can often be a difficult task determining who is the most qualified and best suited to care for pain. And in Tennessee, many insurance plans allow you, the patients, direct access to physical therapy treatment options without a referral from a physician. With this direct access, therapists may be able to work with patients for several visits before they are required to obtain medical certification.
Anesthesia Pain Management Services of Manchester has identified the best chiropractors and physical therapists in our community and are happy to assist you by providing recommendations to reputable providers using proven treatments and technologies. When considering alternative treatments, a good rule is to ask the provider if your insurance will cover costs of treatment. If treatments are not covered by insurance, use caution. Treatments that lack scientific support and evidence are usually not covered by insurance plans. And no matter how good the promises of outcomes may be, always think twice about signing a contract with any provider for services not covered by insurance. Your recovery is unpredictable. Your body may need a week or several months. If a provider wants to see you for a set number of visits and asks for a patient to sign a contract for services, again proceed with caution. We counsel our patients that improvement should typically be seen within 4-5 treatments. If there has been no improvement by this time, then perhaps a different treatment may need to be implemented.
So, when does a patient need x-rays or a MRI? Based on research, x-rays are not typically necessary in non-traumatic back pain for patients between the ages of 18 and about 60. X-rays are more common in the very young and elderly. It is only when injuries are traumatic that x-ray imaging is commonly ordered. MRIs are not commonly performed in acute low back pain unless there is a neurological deficit, concern for fracture, a tumor or infection. MRIs are very sensitive and often provide too much information that is not useful in a pain diagnosis. Too much information can sometimes cause undue concern by patients. For example, MRIs of the lumbar spine are abnormal in about 70% of the population - even in people who have no pain complaints at all. This is also true for the neck as well, but a slightly lower percentage. Because of this, many physicians can assume that an MRI will likely be abnormal. In patients who are experiencing no pain at all, physicians are likely to find abnormalities such as herniated discs, degenerative disc disease and osteoarthritis. So, it is important for providers to ask themselves whether tests are necessary and if the information found will change the treatment plan. In the case of MRIs in the acute stages of low back pain, the findings will not change the treatment plan. Therefore, an MRI should typically not be ordered until after the patient has been initially treated with therapy, chiropractic care, medications and time to heal. If the patient has had these treatments and has not shown improvement, then it would be appropriate for an MRI to be performed.
Here is another example: A patient has had Physical Therapy and/or Chiropractic care, medications and time to heal, but is still in pain. The MRI has now been performed and there is a list of abnormal findings. What is next? This is where interventional spine procedures can aid in the management of the pain. Most people have heard of an epidural. An epidural injection is a common treatment for back pain as well as pain that can travel into the leg, such as sciatica. Second to epidurals, facet joint injections and nerve blocks are often used. These are both effective methods to treating pain, but again it is important for patients to understand where and by whom these procedures are being performed. In the state of Tennessee, many healthcare providers are performing these procedures. In some cases, they are not being done by physicians, but rather nurse practitioners or physician assistants who are not directly supervised by physicians. Here at Anesthesia and Pain Management Services, these services are performed by highly trained, Board Certified Physicians. These procedures can be highly effective, but also carry a level of risk that, when performed in loosely trained or inexperienced hands, can be catastrophic. When seeking out a provider for these procedures, check your research and do not be afraid to ask questions about the providers level of training. A good provider that performs these procedures should have privileges to perform them in a hospital or surgery center, though they may not always need to do so. Hospitals and surgery centers hold their providers to the highest levels of qualifications and do a thorough medical check on each provider and their experience. Providers with privileges will be held to a higher level of expectations than those performing these procedures on their own.
Perhaps the biggest misconception about epidurals or nerve blocks is that they need to be done in a series of three injections. This is simply not true! Each injection should be performed individually, with a reassessment after each and prior to further injections. If a provider immediately focuses on the need for a series of injections, they may not have the patients best interest at the forefront, but are focusing on their own financial gain of the procedures.
Unfortunately, injections are not always the right answer. Some patients will see better results than others. So, if this treatment option does not yield the desired results, what other options are available? This is where your physician may recommend a surgical consultation. Spine surgery is often performed by Neurosurgeons and Orthopedic Spine specialists. The main difference between these two providers is training. Orthopedist complete a spine fellowship prior to performing spine surgery. Neurosurgeons can also complete spine fellowships, but some do not. Just like with therapists and chiropractors, our office has identified the best spine surgeons in Middle Tennessee and are able to provide referrals based on a patient’s individual condition and needs. Surgery should always be considered the last option, and outcomes vary based on the underlying condition. A good surgeon will educate the patient on the potential outcomes and risks. If you are not completely comfortable and informed about a procedure or surgery, then you should continue to ask questions of your surgeon or seek another opinion.
There are rare cases where back pain does not respond to any of the above treatments. I have seen cases where patients have had surgery and do not get better. In fact, in rare cases, some even get worse. Others are not candidates for surgery because of underlying health conditions. Under these circumstances, a patient may be a candidate for a neuromodulation system. This is a device that stimulates the spinal cord through small electrodes inserted into the epidural space though a needle. These electrodes are connected to a small neurostimulator generator that is implanted just under the skin. At Anesthesia Pain Management Services, we are experts in this technology. For more information and videos about neuromodulation, visit our website at www.manchesterpain.net.
Back pain is a common, yet debilitating condition. It is important for people to be informed about their healthcare options. Patients have a choice in their healthcare, and we hope this article has provided a solid understanding of some of the treatment options available. Let Dr. James Nunley, Dr. Marshall Millman and Dr. William Newton at Anesthesia and Pain Management Services be your resource for expert, non-surgical and minimally invasive treatment of any acute and chronic pain affecting the spine and neuromusculoskeletal system. Please contact us at 931-728-5607 for an appointment or visit us at www.manchesterpain.net