Wednesday, January 24, 2018

Back pain solution may be in your head

Back pain is one of the most common health complaints, affecting more than one in four adults every year, and a popular reason for physician visits. But most people recover from back pain whether they're treated medically or not, says Wolf Mehling, a professor of medicine at the University of California at San Francisco.

The American College of Physicians guidelines for back pain generally recommend over-the-counter pain medication, rest and exercise for initial treatment for "nonspecific" back pain, which means pain that is not clearly linked to injury or disease. Yet many people go to the doctor for nonspecific back pain, where they are often given prescription pain relievers and/or are sent for expensive tests. (Of course, if you have severe pain and/or have been injured, you should go to the doctor immediately.)

A recent study categorized treatments offered in nearly 24,000 patient visits for back or neck pain over a 12-year period. (This sample did not include people with "red-flag" symptoms such as pain radiating down the leg, which can indicate a nerve problem.) Prescriptions for opiate pain medication increased, from 19 percent in 1999-2000 to 29 percent in 2009-2010; likewise, referrals to another physician increased from 7 percent to 14 percent, and CT or MRI scans increased from 7 percent to 11 percent. These trends run counter to clinical practice guidelines for acute spine pain, such as those published by the American Pain Society and the American College of Physicians, the study says.

Getting an MRI scan or an X-ray is a reasonable step if back pain has persisted for six weeks or more, the guidelines say. Then, doctors are looking for such possible causes as a herniated disk or a bone spur.

But imaging can be misleading, Mehling says. In "25 percent of people walking down the street with no pain," doctors could find some pathology, he says, such as bulging or thinning disks.

Indeed, says Daniel Cherkin, a senior investigator at Seattle's Group Health Research Institute, "in 85 percent of people, it's not possible to confidently identify a cause of back pain."

With unclear cause, treatment options are murky. Yet many doctors turn to surgery. Twenty years ago, Cherkin documented that rates of back surgery in the United States were double those of many countries' and five times those of the United Kingdom.

"As a spine surgeon, I try to avoid surgery," says Jay Khanna, director of the Johns Hopkins Orthopedic and Spine Surgery practice for the Washington area. For chronic back pain, he recommends physical therapy to strengthen the muscle support for the spine as well as "activity modification," which might mean avoiding bending over or lifting heavy things.

If pain persists, he may recommend injecting steroids or nerve blocks directly into the back. Such injections provide temporary relief from pain — weeks to months for steroids — which might be enough time for natural healing or physical therapy improvements to take place.

Cherkin suggests that doctors and patients take a broader view of back pain to include not only physical causes but also psychological ones. Mehling says two frames of mind make it particularly likely that back pain will persist: "fear of moving — the belief that if you move, you'll make things worse," and catastrophizing — worrying that you'll be debilitated for life.

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