Back Pain Management in Primary Care
A line of reasoning holds that most back pain is the result of walking on two legs rather than four. Without a doubt, bipedalism has numerous advantages but few medical conditions generate more misery than back pain.
And, unfortunately, it’s not a rare problem either, with up to 30% of all adults estimated to be suffering from lower back problems at any given time. You will not be surprised then to know that lower back pain is one of the commonest conditions that we see at the Be Well Medical Center.
Back pain really should be seen as a symptom and not a diagnosis, meaning that there are a large number of possible underlying causes. Occasionally these can be life-threatening but luckily such cases are fairly rare and most of the time lower back pain isn’t dangerous, no matter how severe.
Most back pain arises from either the vertebral bones, the ligaments of the spine or from the muscles nearby. As a group, this is referred to as mechanical back pain. Most often the pain is a dull, constant ache in the lower back or buttocks area. Such pain is commonly called ‘lumbago’.
Sometimes, though, the pain is sharp, burning or stabbing in nature and felt in the back of the thigh, calf or foot. This type of pain is ‘sciatica’ and comes from compression of the sciatic nerve as it exits the spinal cord through narrow spaces made even narrower by arthritis or inflammatory swelling.
Mechanical back pain can occur in anyone and at any age. Some activities, though, make it more likely to happen, especially when combined with underlying risk factors.
It’s well known that back pain typically comes from lifting heavy objects (often with a poor technique or twisting when carrying something) or from bending suddenly without ‘getting loose’ first. Another common scenario is referred to as the “weekend warrior”. This is someone who typically sits in an office all week and then at the weekend hurls himself, in the style of Rambo, into a challenging physical pursuit.
Being overweight is one underlying risk factor for back pain, as is poor ‘core’ muscle condition around the trunk area. These factors are things that to some extent can be fixed but but nobody’s yet found an acceptable way of avoiding the third risk factor for getting a bad back: getting old.
When a back pain starts it can be sudden, severe, alarming and disabling. Our natural tendency is to associate a very severe pain with a very serious underlying problem but in this case the good news is that pain intensity is not a good guide to how serious the back pain problem is or how long it will take to resolve. The worst pains sometimes get better the fastest.
The amount of pain is also not a good guide to who needs x-rays or other investigations. In truth, most people don’t need any investigations at all for their acute lower back pain. It’s been found that X-rays are usually unhelpful and they’re only routinely recommended in cases of trauma or severe osteoporosis (to look for fractures).
Though regularly requested, MRI and CT(CAT) scans are often surprisingly unhelpful too. One reason for this is that the scans themselves can be very hard to read so that different experts may come to different conclusions from the same scan data. Also, over time, it’s been found that many people have scans with abnormal findings (such as bulging or protruding intervertebral discs) but with no symptoms of back pain at all.
Such findings have been seen in almost one-third of twenty year olds and become more common after that age as we get older. Because so many people without back pain have disc damage it becomes very tricky to interpret the significance of seeing disc damage on a scan from a person that does have back pain?
For these reasons, ordering a scan for lower back pain needs careful consideration and shouldn’t be a routine step. Sometimes it sets in motion an almost unstoppable chain of events that ends with a patient having unhelpful surgery.
It is increasingly being recognised that the benefits of surgery are often only modest and may be short-lived. In many cases, the wisest course of action is to steer clear of the surgeon’s “bright lights and cold steel” when looking for a treatment for lumbago.
Because surgery is indicated in only a minority of specific cases and x-rays and scans are often not helpful either, the management of most lower back pain can be undertaken in the community by family doctor clinics, and usually is.
The family doctor’s assessment of a patient with lower back pain will begin with a careful enquiry into the patient’s story, asking about risk factors, the precise mechanism of the injury and any symptoms that might hint at one of the rare but important underlying causes.
An examination follows, looking for atypical underlying causes as well checking whether there are any signs of nerve compression. It’s unlikely that the doctor will request any blood tests or x-rays unless triggered to do so by findings in this assessment.
The usual treatment of a new-onset lumbago or sciatica is normally anti-inflammatory medications and simple, non-opioid (non-narcotic) pain-killers. Sometimes, muscle-relaxing medication may be added too.
In former times, bed-rest was recommended for new-onset back pain. These days we advise physiotherapy instead, to speed up healing by increasing local blood flow (by using ultrasound for example) and to encourage mobilisation through the use of gentle tissue stretches.
Acupuncture is a useful therapy in this setting too and can be just as effective as conventional drug therapy for lower back pain management in certain cases. Acupuncture can also be combined with medication and physiotherapy techniques to relieve pain and promote recovery.
The outlook for a new low back pain problem is generally a good one with over half of all patients becoming free of pain within a few weeks. For those not so lucky, it’s important to find ways of easing the symptoms without using strong pain killers. Narcotic (opiate) addiction is widely seen at the moment in many countries and back pain treatment is often a significant factor in this problem.
When pain is intractable or where there are signs of nerve compromise orthopaedic surgeons should be consulted but for most patients with on-going symptoms it is the complementary practitioners who have the most to offer.
Physiotherapy, acupuncture, osteopathy (or chiropractic) and also psychological counselling all have important and useful roles to play in the management of long-term pain.
Once the acute episode is over, Benjamin Franklin’s dictum that ‘an ounce of prevention is better than a pound of cure’ comes into play. It’s very important to take action against underlying risk factors at this stage and to look at lifestyle and health changes that will lessen the chances of the back pain problem happening again.
A formal weight-loss program and input from a dietician may be worth considering if body size is a risk factor for the individual.
Physiotherapists are an excellent source of advice for rehabilitation of core strength using specific exercises. They’re also the experts on correct stretching and lifting techniques to help prevent recurrent injuries and can advise on the wisdom and benefits of other exercise techniques too, such as yoga, pilates etc.
As mentioned at the beginning of this article, taking up a life on four legs might well help also. However, this is unproven hypothesis currently isn’t part of Be Well’s regular treatment plan for back pain patients!
Thank you for reading. If you have any questions or comments, please feel free to forward them by email to the Be Well clinic.
If you would like to access any of our services mentioned in this article please call 02 111 6644 or contact us by email.
(Be Well Medical Center has physiotherapy services, acupuncture therapy, psychology counselling, dietician services, general practitioner family doctors and a visiting orthopaedic specialist)