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Low Back Pain

From WebMD, the most well-trafficked consumer health information resource (with supplements from Healthline)

  • Symptoms are indicated as “self-inflicted” due to a lifetime of bad habits. Symptoms include nine “red flags” that could point to a serious problem. An “acute” condition is “sharp and sudden” while a “chronic” condition is one that “lasts more than 6 months.”  Doctors are said to “generally” use imaging tests for checking out ongoing pain, including X-rays, an MRI or CT scan, and an electromyogram (EMG)

  • Causes include strains, sprains, cancer of the spinal cord, disc injury (including slipped or ruptured discs), sciatica, spinal stenosis, abnormal spine curvatures, arthritis, fibromyalgia, spondylosis (due to aging), kidney and bladder infections, pinched nerves, infections of the spine, pregnancy, endometriosis, ovarian cysts, and uterine fibroids

  • Treatment includes the following complex array of options: 

    • Home care including RICE (rest, ice, compression and elevation), over-the-counter pain medications, advice to lie on one’s side with a pillow between the legs, warm bath, heating pad or a massage.  For chronic back pain, “sleep on a medium-firm mattress” with an indication to call a doctor if not improved after 72 hours.

    • Exercise and physical therapy (not bed rest) including pilates, aqua therapy, yoga, massage, heat, ultrasound, and whirlpool baths

    • Medications, including narcotics, opioids, antidepressants, and injections

    • Chiropractic and osteopathic

    • Acupuncture

    • Nerve stimulation including radiofrequency lesioning or ablation and transcutaneous electrical nerve stimulation (TENS)

    • Counseling, including cognitive behavioral therapy and biofeedback

    • Surgery, including discectomy, foraminotomy, intradiscal electrothermal therapy, nucleoplasty, spinal fusion, spinal laminectomy, and rhizotomy

  • No prognosis is offered, however, other resources are provided such as

    • Ankylosing Spondylitis Back Pain Relief Tips

    • When Kidney Cancer Spreads to Your Bones

    • Relieve Sciatica Pain 

    • What is Spinal Stenosis?

    • Pain Clinics:  What They Do and How to Find One

The Health Hippo experience

  • Symptoms are organized, with a glossary of terms and pictures, accordingly

    • Acute low back pain (lasting 4 weeks),

    • Subacute low back pain (lasting 4 to 12 weeks), and

    • Chronic low back pain (lasting greater than 12 weeks). 

  • Causes of low back pain are thoroughly described with a note that 84% of adults will have low back pain at some time in their lives. Risk factors include obesity, smoking, age, female gender, physically strenuous work, sedentary work, psychologically strenuous work, low educational attainment, Workers’ Compensation insurance, job dissatisfaction, and psychological factors such as somatization (perceived pain) disorder, anxiety and depression. 

    Importantly, rarely is back pain a harbinger of serious medical illness. 

    • Less than 1 percent of those that see their doctor have a serious problem of spinal cord compression, metastatic cancer, spinal epidural abscess, or vertebral osteomyelitis. 

    • Less than 10 percent have a less serious but specific issue such as a compression fracture or a spinal nerve root issue. 

    • A history and physical is the appropriate starting evaluation and only for specific situations are laboratory studies necessary. 

    • Further, routine imaging (such as MRIs or CTs) is of limited usefulness because these studies often show abnormal findings in adults without low back pain, known as incidental findings. 

    • Finally, “red flags” (other than a history of cancer) are not effective indicators for imaging.

  • Treatment options are thoroughly described and triaged based on supporting evidence of effectiveness, including:

    • Patient education about self-care advice and pain management

    • Non-pharmacotherapy

      • Superficial heat and no bed rest / activity modification

      • Exercise and physical therapy, noting that no particular exercise technique has been demonstrated as superior; selection should be based on preference and experience; in order of complexity

        • Walking

        • Aerobic exercise

        • Community-based programs

        • Stretching

        • Pilates

        • Yoga

        • Tai Chi

        • Alexander technique

        • Directional preference

        • Core exercise and spinal stabilization

        • Graded activities exercise / back boot camp / functional restoration

        • Multidisciplinary (interdisciplinary) rehabilitation

      • Note that massage, acupuncture, spinal manipulation, cold, muscle energy technique, traction, lumbar supports, mattress recommendations, yoga, paraspinal injections all have poor supporting evidence on efficacy

    • Pharmacotherapy

      • Ibuprofen and acetaminophen on a combined dosage is the gold standard pain management pharmacotherapy technique: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791549/

      • Middling evidence exists for muscle relaxants, if sedating effect can be tolerated, and brief duration of opioid / tramadol therapy, if warranted

      • Poor evidence exists for: antidepressants, systemic glucocorticoids, antiepileptics, topical agents such as lidocaine, ultrasounds, interferential therapy, short-wave diathermy, transcutaneous electric nerve stimulation, low-level laser therapy, and herbal therapies

  • Prognosis is excellent as 70 to 90 percent improve within seven weeks. While recurrences are common, in fact 70% of people have a recurrence within 12 months, recurrences also have a favorable prognosis. 

    • Note that exercise interventions, especially to bend and lift correctly and to take a break from sitting or standing, may be preventive, however, lumbar supports, smoking cessation, and weight loss are not demonstrated as preventive.

OTHER RESOURCES TO CONSIDER

  1. National Library of Medicine

  2. National Institute of Neurological Disorders and Stroke

  3. American Academy of Orthopaedic Surgeons

  4. https://choosingwiselycanada.org/treating-lower-back-pain/

  5. https://www.youtube.com/watch?v=RWMKucuejIs

  6. https://podcasts.apple.com/us/podcast/managing-pain-without-drugs-with-dr-phil-page/id1447692260?i=1000435432858

  7. https://www.vox.com/science-and-health/2017/8/4/15929484/chronic-back-pain-treatment-mainstream-vs-alternative