Features September 2018 Issue

Treat Low Back Pain Right

Low back pain is extremely common. But it’s not always treated appropriately.

Most adults in the United States experience low back pain at some point in their lives. But too many of them receive the wrong care, according to a series of articles published in The Lancet (March 2018).

Wrong Care


Low back pain rarely is a medical emergency, yet studies show that people often go to the emergency department with an acute episode of back pain. One study found that about 60 percent of people treated in an emergency department for back pain were prescribed an opioid, even though opioids are discouraged for treating back pain.

Imaging studies have a limited role during the early stages of back pain, yet more than half of people with low back pain receive an imaging study. People with back pain often are inappropriately told to rest and stop work. Only half of people with low back pain are prescribed exercise, which is the most effective treatment.

“The problem is people with an acute episode of back pain often go to doctors who tell them the wrong things, and then the problem worsens because they wait too long to see the right doctor,” says Ellen W. K. Rosenquist, MD, a physician in the Cleveland Clinic Center for Spine Health. “They become deconditioned and it’s a downward spiral.”

What’s Causing the Pain?

A number of conditions can lead to low back pain, and a specific cause is often not identified, according to the articles in The Lancet. The complex array of structures in and around the spine means there are several possible pain generators.

The spine is more than just a stack of bones (vertebrae). There are cushioning disks between the vertebrae and small joints behind each vertebral body that connect it to the one above and below (called facet joints). The bones of the spine are supported by ligaments, tendons and layers of large muscles that go from your head to your tailbone. “They help you to stay erect and move around,” says Dr. Rosenquist.

As we age, disks can degenerate, becoming thinner. Sometimes the soft center of the disk can push through the tough outer layer, causing a slipped, or herniated, disk. You can have osteoarthritis (the wearing down of cartilage) in the facet joints. Some people develop spinal stenosis, which is a narrowing of the spinal canal or the space where the nerves exit the spinal canal.

These may sound serious, but they don’t always cause symptoms. And a herniated disk and spinal stenosis are more likely to cause numbness, tingling and pain down the leg than pain in the low back. This is because it’s the pinching of a nerve that generates symptoms. Nerves in the low back extend down the legs. Osteoarthritis in facet joints may cause pain in the back.

Most Common Cause

The reality is that most pain that is felt in the low back actually comes from stress and strain on the muscles, and other mechanical problems. People can spend too much time working in the garden, cleaning the house, lifting heavy objects or otherwise overworking their bodies. “The next day they can’t move because of muscle spasms, and it has nothing to do with the structures of the spine,” explains Dr. Rosenquist. “Muscle pain can feel really severe.”

Unless back pain is caused by a major trauma or there are certain warning signs that something more serious is going on, treatment starts with simple measures, regardless of the cause. If the pain comes on suddenly and is accompanied by numbness, weakness, fever, or bowel or bladder dysfunction, see a physician right away. These are potential signs of fracture, compressed nerves, infection or cancer.

Initial Treatment

If you hurt your back and don’t have the red flags mentioned above, start by applying heat to soothe the muscles and ice to reduce inflammation. Take it easy for a few days, but continue normal activity as much as possible. Prolonged bed rest is not recommended.

“You want to stretch and be as active as you can,” says Dr. Rosenquist. If you just lie down, the muscles will get tighter and tighter. “Just because you’re in pain doesn’t mean you need a medication,” she says. She recommends trying an over-the-counter patch, such as Salonpas®, which contains menthol and salicylate (the active ingredient in aspirin).

If the pain doesn’t go away in a week or two, then go to your primary care doctor, not the emergency department. Your doctor will most likely refer you to physical therapy. The most important treatment for low back pain is exercises to stretch and strengthen muscles in the abdomen, back, hips and pelvis.

Even if pain does go away, stretching and strengthening exercises are advised to keep it from coming back. The Lancet articles report that about one-third of people with low back pain have recurring episodes. You should consider a first episode of back pain as a sign that it’s time to start a back strengthening program.

Pain Medications

You might be given a medication, but not an opioid. “We use the appropriate categories of drugs that target the specific reasons for the pain,” says Dr. Rosenquist. Nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil®, Motrin®) or naproxen (Aleve®), address inflammation. They should be used unless you have a history of stomach ulcers or kidney disease.

Muscle relaxants, such as cyclobenzaprine (Flexeril®), can be used to calm down muscle spasms. If the pain originates from a pinched nerve, drugs such as gabapentin (Neurontin®) or amitriptyline (Elavil®) might be used.

Opioid drugs, such as hydrocodone (Vicodin®, Lortab®) and oxycodone (Percocet®, OxyContin®), are very powerful painkillers, but they are not recommended for most cases of back pain. “Opioids dull pain sensors, but they don’t target the underlying reasons for pain,” says Dr. Rosenquist. And opioids have the potential to be addicting.

Time for an Imaging Study

If you’re still not better after about six weeks of trying these conservative measures, it might be time for an imaging study, starting with an X-ray. This may help identify the cause. But Dr. Rosenquist points out that degenerative changes in the spine, which may appear on an X-ray, occur normally with age, and they may or may not be the source of symptoms.

Even when symptoms stem from something like a herniated disk or spinal stenosis, initial treatment will be the same as described above. Conservative measures almost always come first. Dr. Rosenquist will sometimes offer patients a steroid injection to be used in conjunction with the other measures.

“What people need to understand is that most of the time a flare of back pain is not serious,” says Dr. Rosenquist. “It usually calms down in a week or two.”

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