Four out of every five people will experience low back pain at some point in their lives, and many will contend with repeated episodes of debilitating pain on and off, sometimes for years. Low back pain is the second most common medical complaint after headache. It’s a leading cause of doctor visits and missed days from work, second only to the common cold.
The annual bill for aching backs, including medical care and disability compensation, may run as high as $50 billion in the U.S. alone. Over the years, the cost of treating back pain has gone up and up—and yet there is no indication that this extra expense is resulting in healthier, happier people. In addition to the discomfort and the expense, back pain compromises people’s overall quality of life, making it hard to work, exercise, and travel.
Every year, many articles and books about back pain are published, espousing new and old theories about its causes and how to treat it. However, there’s lots of room for controversy because the back is such a complicated, sophisticated structure. While we can name all of the bones, joints, nerves, muscles, and ligaments, the sum total remains something of a mystery.
The following interview with William Pereira, M.D., M.P.H., is adapted from our Wellness ReportHow to Manage Back Pain, of which he is the co-author. Dr. Pereira is Associate Chair of the Editorial Board of the UC Berkeley Wellness Letter and is board-certified in occupational and environmental medicine. He has over 30 years of clinical experience in occupational, preventive, primary care, physical and emergency medicine.
Q. When should someone with back pain see a doctor?
A. If you have simple low back pain and you have adequate control of the pain, you don’t need to see a doctor. But if over-the-counter pain relievers don’t help enough, or if there are symptoms such as lower-extremity pain, numbness, tingling, or weakness in the lower extremities, loss of bladder or bowel control, or fever, you should see a doctor.
There’s no hard line with simple low back pain, which is defined as pain that is nonradiating or radiates just a bit into the buttocks or thigh, without any of the other symptoms I just mentioned. I myself have chronic low back pain and chose not to seek medical attention for about a year and a half.
Q. If a person has gone to a primary care doctor for back pain and that hasn’t helped, who should he/she consult next?
A. It can be difficult to find the right doctor. Many primary care providers, particularly internists, are not geared to addressing the musculoskeletal system. Depending on their interests and experience, some are really good with backs, and some are not. Luckily, even if that is not their forte, most primary care doctors can help patients manage simple low back pain.
If standard measures don’t solve the problem, your doctor can refer you to a specialist. The logical choice would be someone who deals with backs all the time. There are orthopedists, some of whom specialize in backs, and physiatrists, who specialize in physical medicine and rehabilitation. There are also neurosurgeons who specialize in back problems.
Doctors in my specialty, occupational medicine, see patients with low back pain all the time, but we normally treat it only when it is work-related, although some of us do work at urgent care clinics and so are available to the public.
Many patients ask about spinal manipulation. It may help sometimes, but I’m hesitant to rely on it as a stand-alone treatment. Different types are done by physical therapists, osteopaths, and chiropractors. With physical therapists you also get the rest of physical therapy, including education about your back. Most physicians treating simple low back pain will prescribe physical therapy if things don’t improve with self-care and medication.
Q. What are the most common misconceptions about back pain?
A. The traditional notion has been that simple low back pain will go away within a couple of months. That’s not necessarily the case. It’s true that most episodes of acute low back pain get better eventually, even without treatment. If it’s your first episode, and if it came on suddenly when you zigged when you should have zagged, and if there are none of the warning signs I mentioned previously, then the pain is likely to resolve on its own. However, if it has come on gradually and you can’t really say exactly when it started or why, that sort of pain will often drag on.
The question is what to do about it. I have localized low back pain that waxes and wanes but won’t go away. My primary care physician prescribed physical therapy. While that didn’t rid me of my pain, I have incorporated the exercises I was taught there into my self-management regimen, and they’ve helped me deal with the pain. I also tried deep tissue massage, which helped, but only temporarily.
I still have the low back pain, and I am back to self-managing for now. What steps you take are often dictated by how much the pain interferes with your quality of life. There’s no one answer for everybody.
If you have no symptoms other than localized pain, it’s okay to self-manage. But if the pain persists and you can’t stand it anymore, or if any of the warning symptoms I mentioned are there, then seek some help.
Q. What do you think about exercise and physical activity for back pain?
A. The more, the better, as long as the activity is not making your back pain worse. I tell my patients with any injury to stay as active as they can. If it hurts, don’t do it—but if it feels okay, do it. As for specific exercises and stretches, because simple back pain can involve such a variety of underlying conditions, it’s best to consult a physical therapist or other professional about which ones would be best for you.
Q. What about using heat versus cold?
A. I get asked this question all the time. The classic dictum is if you acutely injure something, re-injure it, or aggravate it, then icing is better. And when it’s been bothering you for a while and it’s sort of stiff, then heat is better. But in fact, particularly with backs, all bets are off, because some people respond better to one than the other. So I tell patients to experiment. Try cold, try heat—and some people like to alternate cold and heat. Again, your body will guide you.
Q. Are osteopaths generally better at treating back pain than standard medical doctors—or is that a myth?
A. It would make sense that osteopaths (doctors of osteopathic medicine) have an advantage here in that, while overall medical education is the same for both osteopaths and other doctors, osteopaths get additional training in manipulation that gives them a focus on the musculoskeletal system. So, theoretically, yes—but it’s not true across the board by any means. And I don’t know of any studies that show that osteopaths are better than other doctors at treating back pain.
On the other hand, physical therapists are trained in manipulation, too. So if a doctor feels that manipulation may be of benefit, he/she can send a patient to a physical therapist for it.
Q. What about chiropractic treatment?
A. I tried it, and it didn’t help with my back pain. Actually, I’m more pro-chiropractic than a lot of people in my profession, but my opinion is based more on personal and anecdotal experience than scientific studies. When I was practicing emergency medicine in my late twenties, I thought that chiropractic manipulation could not possibly be of benefit, because that’s what I’d been taught in medical school. And the founding tenet of chiropractic, that it diagnoses and treats so-called “subluxations,” which are supposed to be responsible for most bodily ills, is certainly nonsense. In any case, a couple of close friends whose opinions I respected said they’d been really helped by chiropractic treatment for back problems, so I had to check it out for myself.
Sure enough, though I wasn’t being treated for any particular musculoskeletal problem at the time, I got to the place where I could tell when my back would benefit from an adjustment. It was a really interesting experience.
It’s hard to generalize because chiropractors are all over the map. Some think that chiropractic can cure everything, that children should not be vaccinated, and that anything “allopathic” (meaning mainstream medicine) is horrible. Others are more reasonable. Interestingly, in Germany there are no separate chiropractors. There, medical doctors who have taken a postgraduate course in chiropractic manipulation perform that function.
I do think manipulation can be helpful for some cases of back pain, but so far studies aren’t able to give us the whole picture. The Wellness Letter does evidence-based reporting, so the problem for us is how to advise people about those areas where there isn’t sufficient and convincing evidence. You have to go by your experience and/or your gut instinct.
Some alternative treatments for back pain may have some benefit, but it’s hard to say what, when, where, and for whom. We do try to steer patients away from things that are likely to hurt them.
Here’s an example: It would not be prudent to take an herb that’s known to be toxic. But if it’s not harmful, that’s different. I had a Chinese patient who asked me if using a topical Chinese herb was okay. She said that rubbing it into the skin overlying her pain gave her hours of relief, and I said that it was fine to continue using it. It’s unlikely to be toxic, and for her it helped. How much of its efficacy was just the placebo effect because she believed in traditional Chinese medicine? I don’t know. But in terms of treating a patient, I don’t care whether it was the herb or a placebo effect that helped—as long as no harm is done and we don’t disregard the underlying cause.
Q. Do you ever refer patients to acupuncturists?
A. All the time, and a lot of them get relief from it. The one I send them to most often happens to be a doctor who got into acupuncture later. There’s a large Asian population in the Berkeley area, so there are many acupuncturists to choose from. But the results are variable. Some people get really good results from acupuncture or acupressure, and others find it’s a waste of time. So it’s something to have in your therapeutic armamentarium. Particularly if nothing else is working, give it a try!
Q. What about the “psychosocial factors” involved in low back pain?
A. That’s a tough one, because as soon as doctors say “psychosocial factors,” patients wonder, “do you think this is all in my head, doc?” But it is nonetheless true that pain and psychosocial factors are hard to uncouple. For example, I see a lot of patients who have repetitive strain injuries, and any time you have a chronic injury, there’s the possibility that it will be linked with either depression or stress. And what caused what isn’t clear.
Every time there are problems like our economic downturn, or when there are massive layoffs or the threat of layoffs, injuries go up. And why is that? Generally, there’s a correlation between upsetting life events and mood and health problems. I mean, I’ve never treated a psyche [mind] without a soma [body] or a soma without a psyche. They’re always both there.
I’ve found that the best approach is to deal with both—that is, don’t ignore either the physical or the psychosocial aspects. If my pain is making me feel depressed, when I help my pain, I’m also helping my depression. Conversely, if my pain is in some way connected to my depression, then dealing with my depression will likely benefit my physical problem. If you deal with both, you’ve got your bases covered.
I always ask patients how they’re feeling emotionally and whether they’re under a lot of stress. If so, I have them go get a “stress consult” with a psychologist. They spend just an hour and find out if there is anything more they can be doing to deal with their stress or any other psychological issues.
Another aspect of this: When you’ve got something that’s causing chronic pain, it’s a “downer,” and that tends to affect your nervous system, so anything you can do that’s an “upper” can help to counterbalance that. I advise doing things that are fun and make you feel good. It can be something as simple as taking a walk, calling a friend, treating yourself to a great meal. Do things that are telling your nervous system, “Oh! I’m happy!” instead of “Oh, I’m miserable.”
The whole mind-body connection is a “soft” area, and often not a straightforward thing. Statistics show that if you put people under stress, or if something is making them depressed, they’ll have more injuries and more pain, on average. But as an individual, you can’t really say, “My boss was angry at me and that’s why I hurt my back.”
Q. What about imaging tests like MRIs? Have you had them done for your back?
A. No, I haven’t. Doctors often order MRIs to pinpoint the cause of chronic back pain. Though excellent for confirming certain diagnoses, MRIs of the spine produce far too many false alarms to be a good routine test for people with nonspecific back pain. That is, the scans may reveal an abnormality that’s assumed to be the cause of the pain, but isn’t, potentially leading to unnecessary and possibly risky treatments.
The fact is, MRIs find spinal abnormalities in most people, including those who have no back pain. Such “false-positive” results help explain why the rate of back surgery in the U.S. is more than twice as high as in other countries—and why, all too often, the surgery doesn’t help. In many cases, surgery corrects a “problem” that is unrelated or incidental to the cause of the pain.
Unless a decision has already been made to have surgery, if your doctor wants you to have an MRI for your back, you should consider getting a second opinion.
Q. If most people with non-specific low back pain improve eventually, even without treatment, is “watchful waiting” generally the wisest course? When should people consider surgery?
A. I’m all for watchful waiting, provided there are none of the danger signs. Surgery is usually advisable only if you have an obvious, specific, surgically treatable cause of low back pain. Even then, the outcome statistics suggest that, for a number of conditions, you may end up about the same after a year or so whether or not you have surgery. The question is, what sort of year will that be? If you have back surgery, generally your pain goes away faster. At the end of the year, you might be about the same as someone who didn’t have surgery, but in the meantime, you haven’t had to deal with as much pain.
You’re most likely to have a good outcome from surgery when there’s a demonstrable, physical cause of the problem. Unless that’s the case, I wouldn’t opt for surgery unless it was my last option and I was so miserable that I couldn’t endure the pain.
For example, I recently helped with the post-op care of a friend who had spinal stenosis. They could point to it on the X-ray and MRI and say, “Look right there, we can see what’s happening. We can do this [procedure] and there’s a good likelihood that you’re going to get better.” She was substantially better after the surgery. That’s a typical outcome under the circumstances. Not guaranteed, of course, but it makes sense.
Let’s say I have spondylolisthesis, however, where one vertebra slips forward on another. The surgical treatment is fusion of the affected vertebrae. But what exactly is it that’s causing my pain? Is it the actual slippage or something else? Is surgery really going to help? Some people have fusion surgery and are helped by it, and some people aren’t. In these cases, it’s probably a mixed bag as to what’s causing the symptoms. So if I had spondylolisthesis, I’d try to get by without surgery first.
Q. Based on your own experience with back pain, do you have any other insights?
A. For the last couple of years my low back pain has been pretty constant. Nobody can quite figure out what brings it on or what makes it go away. If it gets bad, I take something for it. Unfortunately, I can’t take nonsteroidal anti-inflammatory drugs (NSAIDs, such as aspirin and ibuprofen) because they upset my stomach, even if I take one of the medicines that turn off stomach acid production, so I’m limited to either prescription narcotics or the steroidal anti-inflammatory drugs (often referred to simply as “cortisone”), such as prednisone. For a time, I found that just a single dose of prednisone would make the back pain go away completely for a week or more.
At one point I had an episode that didn’t go away after a single dose of prednisone. Sometimes I put patients on a 10-day to two-week course of prednisone, so I thought I’d see if that would help as well. It worked for the time I was on the medication—I had absolutely no pain for those 10 days—but as soon as I stopped taking the prednisone, the pain came back.
So now, if the pain is bad enough that I can’t focus on anything else and it’s interfering with my life, I take a narcotic instead. Taking prednisone or another "cortisone" type of medication more than occasionally can also be dangerous.
Interestingly, if I really get engaged in something, I can often forget about the pain, even when it’s more intense, and then I don’t need to take anything for it. I do a set of stretches daily, and sometimes the pain goes away after doing them. Exercise, particularly walking, often helps, so I try to walk regularly.
I see my back pain story as “to be continued.” I’m living with the pain—it’s manageable. It’s most likely degenerative, and degenerative diseases often “settle down” eventually.
Q. You mean the chronic pain gradually diminishes?
A. Yes. You don’t necessarily have the pain forever. For instance, a few years ago I injured my right shoulder. The moment I did it I knew it was going to take at least a year to heal because of the nature of the tissues involved. It’s about three-quarters better now after two years, and I haven’t done anything other than avoiding activities that make it hurt.
As you get older, you have to deal with degenerative processes. But if the problem has gotten to the point where there’s nothing more to degenerate, or the degeneration is no longer triggering a pain response in the nerves, then the pain often goes away.