As a physician treating pain conditions, many patients have told me that their backs had “gone out” but I never appreciated what a fearful experience it could be until it happened to me. More than a decade ago, after moving some furniture in the house, I found that the next day, I could not straighten up after getting out of bed. My back had “gone out.”
Puzzled and a little alarmed I hobbled to work and soon realized I had to take the advice I had been giving to patients for years regarding conservative treatment. The “problem” resolved completely in 5-7 days. Still, episodes of back pain and stiffness and difficulty putting weight on my legs have recurred over the years, making me sympathetic to my pain patients and giving me a continual chance to “take my own advice.”
For example, I am always mindful of the very poor correlation between information shown on diagnostic imagery and the diagnosis and treatment of chronic pain. Like so many of my patients, the MRIs taken of my back when it “went out” revealed arthritis, “degenerative disc and facet joint arthritic changes” and spondylosis which are all normal for my age and were not the cause of the pain. They are physiologic changes that are part of aging and as normal and expected as grey hair.
As I counsel my patients, I quickly realized my lower back pain episodes could be prevented by lifestyle changes, regular exercise, losing weight and stress management. Like my patients, I needed to practice self-management, self-efficacy, and self-care. By making a commitment to these practices I have been able to avoid injections, surgery, and drugs.
My own experience caused me to consider a new paradigm in understanding and educating patients about acute episodes of lower back pain. No one in the general population or the medical community fails to understand the concept of a heart attack—an acute episode of chest pain, associated with ischemia to the heart. Even when a heart attack is mild or does not require surgery, it is regarded as a sobering “wake-up call.” Once stabilized, the physician will advise the patient to enact lifestyle changes like losing weight, exercising, eating better, decreasing cholesterol, decreasing stress and of course to cease smoking if he smokes. Risk factors for a future heart event like high blood pressure, diabetes and increased cholesterol will be closely watched.
Yet a similar change in attitude and wake-up call doesn’t happen with a “back attack” even though a lower back pain episode is followed by additional episodes if no changes are made and the back attack is almost always a culmination of unhealthy life decisions!
Of course, 1 to 5 percent of patients who have a back attack may be experiencing fracture, progressive neurological problems like cauda equine syndrome, infection, cancer, visceral problems like pancreatitis, and aneurysms which require quick and aggressive medical and possibly surgical treatment.
But most “back attack” patients have no serious disease or condition and their pain will be self-limiting and resolve with time. Studies on the natural history of back pain show that 30 to 60 percent of patients recover in one week, 60 to 90 percent recover in six weeks and 95 percent recover in 12 weeks. The bigger medical problem is relapses and recurrences which occur in about 40 percent of patients within six months.
Since the 1960s, cardiac rehabilitation has been the gold standard to prevent subsequent heart events. It encompasses multiple factors like graded mobilization, risk reduction, nutritional counseling for weight and lipid reduction, psychological and vocational counseling, smoking cessation, stress reduction, and self-responsibility. Cardiac rehabilitation team members have included physicians, cardiologists, therapists, nurses, nutritionists and psychologists.
The same multifactorial approach should be routinely employed for “back attacks” for the same reasons; if a patient continues to live in the same way, he or she risks a repeat of the medical events.
In the case of my own “back attack” and multitudes of patients who sustain them, there is little rationale to obtain diagnostic imagery unless red flags are present. Conservative treatment with one to two days of bed rest, followed by reactivation, medications and thermal modalities (cold/heat) for comfort and physical therapy over a period of 2 to 6 weeks, are sufficient.
I believe a back pain paradigm based on the heart attack paradigm can help the millions affected by repeated episodes of lower back pain in understanding their condition and susceptibilities and preventing further “back attacks.” Rather than “medicalizing” an attack of lower back pain or a “back attack,” this new paradigm would help patients avoid the current odyssey of multiple surgeries, injections and chronic opioid use—which only worsens pain as it adds to health care and societal costs.
Sridhar Vasudevan, M.D., is clinical professor of physical medicine and rehabilitation (PM&R) at the Medical College of Wisconsin in Milwaukee. This is an excerpt from “Multidisciplinary Management of Chronic Pain: A Practical Guide for Clinicians” available from the global publishing company Springer.