The Pain Game
Aching back? You probably don’t need surgery.
WHAT DO JOHN F. KENNEDY, TIGER WOODS AND HULK HOGAN HAVE IN COMMON?
This may sound like a joke, but the punch line is anything but funny: all three were/are formerly vigorous people who suffered chronic back pain that multiple back surgeries failed to ease. That also gives them something in common with millions of Americans, since low-back pain is one of the top complaints that brings patients to doctors’ offices, and surgery is rarely the answer.
According to Dr. Brian Su, a surgeon in chief with Mt. Tam Orthopedics and Marin General Hospital’s Medical Director of Spine Surgery, a common misconception among patients is that surgery will cure the chronic back pain that plagues so many of us.
“It typically cannot,” Su says. “I do surgery for back pain, but they are very select patients. The vast majority I turn away.”
Surgery is probably not necessary even if a scan shows scary-sounding things like a herniated disk, multilevel compression, pinched nerves or degenerative disk disease, he says. In fact, a 2016 review of the literature confirmed what was already common knowledge among spine surgeons: for 95 percent of chronic lower-back-pain patients, a cause can’t be pinpointed, meaning that surgery is not a good idea.
Perhaps surprisingly, an MRI doesn’t always help doctors find the cause of the pain. Research has shown no nonspecific correlation between abnormal MRI scans and lower back pain.
“Ninety percent of people over 60 years of age have abnormal MRIs. I always tell patients, we’re not here to treat your MRI — we are treating you,” Su says. Accordingly, the American Academy of Family Physicians recommends against doing a scan within the first six weeks of back pain, in the absence of red flags such as trauma or fever.
And so many patients complain they still have back pain after a surgery that it’s understandable why Su — and pretty much all medical authorities — recommend trying just about anything else to ease chronic back pain before considering surgery. (This is assuming your doctor has ruled out an injury like a fracture or illness such as cancer or a rare emergency disorder known as cauda equina syndrome.)
A prescription is rarely the answer either. The use of painkillers for chronic pain is rapidly falling out of favor now that the opioid crisis has made apparent the outsize risks of OxyContin and similar drugs. When Woods was arrested after being found asleep at the wheel earlier this year, six weeks after his fourth back surgery, he was found to have two opioid drugs in his system. He later completed a drug treatment program.
Su’s practice has “drastically” reduced prescriptions of opioids, with the exception of postsurgical patients, he says.
With surgery and painkillers off the table for most patients, what to do about the persistent pain that can make it difficult to sit, work, even sleep? Fortunately, you don’t have to give up and bear it. There are noninvasive treatments that patients say really help.
HEAT, MASSAGE, CHIROPRACTIC CARE OR ACUPUNCTURE
These are first on the American College of Physicians’ 2017 guidelines for treating acute and chronic low back pain. While there isn’t strong evidence behind these treatments’ effectiveness, the risks are low and doctors say they’ve seen some patients benefit. For chiropractic care, Su recommends muscle release over adjustments.
If you hurt your back and the doctor recommends ibuprofen or aspirin, pay close attention to the dose the physician recommends — it’s probably a higher dose, for a longer duration, than you’d think.
“The mistake most patients make is that they pop a couple ibuprofen and say they feel a little better, and then that’s all they take,” Su says. “Even if you don’t have pain, take it. Because it builds a baseline level of anti-inflammatory in your blood, and that actually treats the inflammation.”
Of course, all drugs have side effects and risks. The Food and Drug Administration has warned that nonsteroidal anti-inflammatory drugs including ibuprofen can increase the risk of heart attack or stroke, so don’t start a regimen without consulting your doctor.
Osteopathic physicians undergo a different training protocol than medical doctors, with a focus on the whole person. Some specialize in manual therapy, using their hands to manipulate the patient’s body. If you bring your aching back to an osteopath such as Novato’s Dr. Maud Nerman, you can expect the physician to feel your back and hips for out-ofplace parts and gently guide them back into position.
“About 70 percent of the time that somebody has low back problems, the sacrum is in the wrong place,” Nerman explains. “It’s either pushed up, which would squeeze the lumbar disks, or it’s at an angle — which can happen if there’s a fall or a car accident. Most of the time when you get the sacrum back in place, the back pain goes away.”
A 2013 review of the research on osteopathic intervention for chronic low-back pain found some evidence for effectiveness, but called for more rigorous clinical trials.
While more commonly used for nerve pain, such as sciatica, steroid injections are one option Su’s clinic sometimes offers to temporarily ease lower-back pain. Even though the Journal of the American Medical Association recommends against these injections for back pain alone, Su has found they can bring short-term relief for an injury to or arthritis in the spinal joints. But he advises against repeated use, which can cause a loss of bone density.
PHYSICAL THERAPY AND EXERCISE
While many physicians prescribe physical therapy to teach patients pain-relieving stretches and exercises, the research doesn’t conclusively support it: a 2015 study found only a small difference in the recovery of patients who attended four PT sessions and those who didn’t. The PT patients did recover their ability to move freely more quickly, but there was no difference in pain.
Still, it could be the typical PT regimen just doesn’t cut it. In 2008, Marin investigative reporter Cathryn Jakobson Ramin set out to find the solution to the back pain that was holding her hostage; later she chronicled the effort in her 2017 book Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery. Ramin, who tried pretty much every noninvasive treatment out there, found that when it comes to PT, most patients get one-size-fits-all regimens that aren’t intensive enough to help.
A recent Finnish study corroborates her view, finding that a personalized PT regimen yields better results. Attitude also matters; if you approach PT as something merely to get out of the way before you can have surgery, it probably isn’t going to work.
Ramin concluded that the PT most likely to succeed is led by a doctorate-level therapist who’s also an orthopedic clinical specialist able to launch patients on a “custom exercise-based rehabilitation program.” Such programs can take weeks and require a lifelong commitment to keeping up the exercise on your own, but for Ramin and many patients she writes about, they were the key to lasting relief. Unfortunately, they’re often not fully covered by insurance.
The concept that exercise can ease back pain makes sense if you listen to the many experts who told Ramin that the problem often stems from muscle weakness associated with a sedentary lifestyle. In fact, the doctor who finally helped relieve JFK’s back pain blamed weakness exacerbated by failed back surgeries for his patient’s pain. The answer for Kennedy, and others including Ramin: strengthening exercises, performed religiously. Many people find it helpful to maintain an ongoing relationship with a trainer well versed in spine health.
Su agrees exercise to strengthen core muscles can do a lot to prevent and relieve back pain, but says it also helps in another way — weight loss. “Belly weight increases pressure on the disks,” he points out. “Most people are able to eliminate the need for surgery by losing weight.”
If you can’t find or afford a back rehab program, don’t despair; other physical activity, such as tai chi or certain types of yoga, may be effective. You can find exercises on YouTube; Ramin swears by Canadian biomechanics professor Stuart McGill’s “Big Three” exercises.
Since research has shown that stress hormones such as cortisol can promote chronic pain, it’s not surprising that some rehab programs for back pain also include a psychological aspect. Studies show that cognitive behavioral therapy, mindfulness, and other psychological interventions can be effective components of treatment.
Perhaps the surest ticket to recovery is patience. According to the American College of Physicians, “Most patients with acute or subacute low back pain improve over time regardless of treatment.” Try some of the noninvasive tactics listed above to ease the discomfort, and wait it out.