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Back Pain Problems
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“She killed herself,” a friend of mine told me of a co-worker. “After years of chronic back pain, multiple surgeries and heavy pain medication, she had had enough.” This kind of tragedy fortunately doesn’t happen very often. Much more likely, a person with chronic or recurrent back pain just learns to “live with it.” When her back ‘goes out’, she restricts her activities, may take time off from work and, with medication, a certain amount of grit, and whatever other form of therapy she chooses, waits it out. Does this sound familiar? Karen Karen, a young woman in her early thirties, had over a decade of activity-related back troubles. Over these years, she saw many different kinds of health professionals. She had x-rays, MRI (Magnetic Resonance Imagery) and other tests and received many different diagnostic labels for her recurring problems. Treatments she received included pain medication, hot packs, electrical stimulation, spinal manipulation and exercises. During these years she had four particularly bad episodes during which time she was briefly hospitalized and then placed on extended bed rest. After one such recurrence she went to an orthopedic surgeon who neither looked at her back nor examined her. After hearing some of her history, he said, “Why haven’t you had your disc removed?” “What’s the alternative?” she asked. “Whining for the Rest of your Life,” he replied. She did not return to his office. At various times Karen also saw a number of chiropractors. While adjustments (the chiropractic term for spinal manipulation) sometimes seemed to help for brief periods,there were times when they didn’t help or seemed to make her worse. Chiropractic adjustments, she found, could be applied in the same rote way as some of the other treatments she had gotten from physicians and therapists. Some chiropractors she met also emphasized returning for frequent and periodic adjustments, even when she didn’t experience a problem. Following each episode, Karen often got advice to stay active, do exercises and work on her posture. However, typically she would be handed a few stapled sheets of paper with generic instructions. Occasionally, she was given more personalized attention, not all of it helpful. During one episode when she experienced pain in both her back and leg, a physician showed her an exercise he wanted her to do. As she lay flat on her back, she was instructed to pull one knee to her chest. After several repetitions, the pain in her leg increased and shot down into her foot. “Try not to pay any attention to it,” he told her as the pain in her foot increased. She finally stopped the exercise, in tears. She recalls a more positive experience when a physical therapist patiently answered her questions and worked with her on the exercises he gave her. The therapist got into trouble for the extra time he spent with her. On her next visit, she was treated by someone else. She became resolved to “live with my problem” until, by a set of chance circumstances, she came to see me. Back Pain Problems The Diagnostic Daze In their efforts to come up with a diagnosis, some practitioners may give too much credence to x-rays and other kinds of diagnostic imagery that do not always correlate neatly with the symptoms that people experience. By now, many studies have been done that show a significant lack of correlation between symptoms experienced and what one sees on diagnostic imaging.6,7 Among a group of people who reported never having had back pain, about 20% had herniated discs according to MRI studies. Of this same group, about 50% of those under 60 and almost 80% of those over 60 had bulging discs.8 This does not mean that arthritic changes or a bulging or herniated disc can never cause back pain. It does mean that having these visible problems on your x-ray or MRI does not necessarily mean that you will have pain. In addition, many of the other potentially problematic parts of the back cannot be seen on x-rays or MRI images, or detected with laboratory tests. Diagnosis and treatment should not be based solely on imaging results. People like Karen may become unduly frightened by practitioners who conclude more than they ought to from such tests. For physicians and other health-professionals, who want to know what specific part of the spine is affected, these diagnostic difficulties can seem particularly frustrating. Once serious disease or surgical emergencies (often much easier to detect) are eliminated, we are left with what has come to be called “non-specific back pain,” which accounts for the majority of all episodes. Despite these diagnostic problems, many different groups of practitioners have made an effort to explain as well as they can what happens when someone’s back hurts. Different explanations may imply different treatments. There are a variety of approaches, not all of which seem compatible. As Karen discovered, the diagnosis that a person with back pain ends up with may depend more upon whom she has seen than on anything else.9 Chiropractors may diagnose “subluxations.” Rheumatologists may diagnose “arthritis,” internists “low back muscle strains,” orthopedists “herniated discs.” Might all of these diagnoses be equally correct? Or might all of them be more or less wrong? If there is some ‘truth’ to at least some of them some of the time, how much and in what way? Even though, or perhaps because, any one practitioner or group of practitioners may show a great deal of assurance in their particular viewpoint, the area of back care as a whole teems with diagnostic and explanatory confusion. As a result, people like Karen often feel confused as well. Questioning Traditional Treatments For years, a few lonely voices challenged this emphasis on rest in treating back pain. For example, in a 1947 article in the British Medical Journal entitled “The Dangers of Going to Bed,” R. A. J. Asher wrote, “It is my intention to justify placing beds and graves in the same category and to increase the amount of dread with which beds are usually regarded...There is hardly any part of the body which is immune to its dangers.”10 More recently, the number of questioning voices has grown. By now, numerous studies have challenged the importance of bed rest as a significant treatment for back pain and sciatica (back pain which radiates into the leg).11 It is now more widely understood that unduly restricting activities with enforced bed rest can lead to further problems of immobility and disuse.12 These days, Karen would not be advised to stay in bed so long! The other widely applied passive treatments that Karen received, such as heat, ultrasound and electrical stimulation, although they may temporarily ease symptoms, have also been de-emphasized. As the Agency for Health Care Policy and Research (AHCPR) guidelines panel noted in their 1994 report , “The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost. As an option, patients may be taught self-application of heat or cold to the back at home.”13 Someone like Karen probably benefits now from another growing trend: reduced willingness to do surgery. Back surgery rates in the United States have been among the highest in the industrialized world. When “failed back surgery” became a diagnosis in its own right, some people began to wonder if these higher surgical rates did equal better healthcare. Despite the attitudes of a few surgeons like the one that Karen met, surgery now has a much smaller role in treatment than previously thought. This leads to more options for the person with back pain, as well as better results when surgery does seem necessary. Karen’s experiences with chiropractic treatment represents the experience of many as well. 40% of those getting care for back pain see a chiropactor.14 As Karen discovered, spinal manipulation (movements applied to the joints by a practi-tioner) can sometimes provide relief. Some research evidence indicates that such treatment can provide short-term benefits. However, as Karen discovered, the long term benefit of such care is not clear. Her confidence was not encouraged by practitioners she met who used this approach as the major part of their treatment and encouraged her to return again and again for adjustments. When Time Doesn’t Heal All Wounds The expense of dealing with back pain is staggering. By the end of the twentieth century, lost productivity cost U.S. industry more than $28 billion dollars per year. The added costs of disability payments and medical costs may have brought the total loss to more than $50 billion dollars in the U.S. alone.17 For the sufferer, the expense of continuing or recurring pain involves, in addition to monetary loss, discomfort and emotional distress. Is watchful waiting and encouraging general activity enough to deal with this epidemic of disability? Is passage of time sufficient? As Karen learned, she was indeed likely to improve somewhat from any particular episode. However, afterwards she still experienced some pain, restriction and weakness. Having had a series of episodes over many years, she expected future disabling recurrences as well. What then did “getting better” mean? Although some authorities still seem to believe that most patients recover quickly and spontaneously from an episode of back pain, evidence belies this. Researchers in Great Britain found that a much larger percentage of patients than expected had continuing severe symptoms a year after onset.18 Israeli researchers found that although the back patients they studied did improve over time, most of them continued having some pain and functional limitations at a two-month follow-up.19 Recurrence of back pain also remains a persistent and widely recognized problem.20 It may be true that for some people each episode will be similar with similar periods of recovery. Unfortunately there is little evidence that everyone can expect full recovery with typical present-day treatment. For a significant minority of people, ongoing symptoms remain. Some of those who have gotten at least some relief, may have continuing and worsening recurrences. Some develop sciatica, which can include lower limb pain, tingling, numbness and weakness in the muscles of the leg. This syndrome is commonly preceded by recurring episodes of back pain. Activity and Exercise But what activity and exercises are best for an individual? Some practitioners seemed to have a theoretical rationale for telling her to do one thing or another. Some doctors told Karen that, as long as she kept active, no particular exercise seemed best.22 When it came down to actually doing exercises, Karen was often given generic exercises with only vague guidelines about when to continue in spite of pain or when to stop because of it. Karen’s confusion about exercise reflects the state of research on exercise and back pain. Different theories may explain why an exercise should work or why an activity is useful or harmful to the back. These theories may or may not be sound. How can anyone know? Based on their survey of various statistical studies, the British Royal College of Physicians stated this in its Clinical Guidelines for the Management of Acute Low Back Pain: “On the evidence available at present, it is doubtful that specific back exercises produce clinically significant improvements in acute low back pain or that it is possible to select which patients will respond to which exercises.”23 This vagueness and skepticism regarding exercise as well as other forms of back treatment results in part because much of modern healthcare has become overly dependent on a particular, narrow, view of research. A growing number of healthcare practitioners advocate what they call ‘evidence’-based practice. It seems ironic that some advocates of this approach emphasize the usefulness of only one form of evidence: information gained from the statistical study of large groups of people. This kind of information can be useful for making correlations between types of treatment and general outcomes for groups of people. If you want to know whether a particular treatment works on the average, you need this kind of study. However, there is information that can never be gotten from doing this kind of research. Statistical studies will never tell you how a treatment works or how an individual functions, although it may suggest ideas. Neither can any statistical analysis tell anyone exactly how a particular individual, like Karen or you, will respond to a particular treatment. At best it can only provide probabilities. Depending too much on group statistical methods thus promotes a generic approach to activity and exercise. Such an approach seems well-suited to the mechanized practice of medicine and healthcare that some insurance companies and HMOs have come to encourage. The individuality of each patient can easily get ignored and forgotten in the push to compile statistics and cut costs. Fortunately, other methods of research are available. If you take the attitude of a personal scientist in regard to your own problem, you don’t need to remain completely in the dark about what and what not to do. You can apply the method of possibilities, as discussed in the last chapter, to discover what works for you. Every person is a unique and different individual. Although similar to others, you are not exactly the same in all respects as anyone else. Therefore, it follows that particular activities and exercises will have their own specific effects on you. By closely observing these effects, it is possible to determine what works best for you. A practitioner who follows such a scientific approach can help you in applying it to your problem and you can learn to do it for yourself (see Chapter 10). The Problem with ‘Posture’ Her experience reflects a significant consensus regarding posture among these different groups. For example, a brochure on Low Back Pain issued by the American Academy of Orthopedic Surgeons states, “The best long-term treatment [for lower back pain] is an active prevention program of maintaining proper lifting and postural activities to prevent further injuries.”24 The American Physical Therapy Association Book of Body Maintenance and Repair states, “Posture has significant implications for the general health and well-being of much of the body…The back, and the lower back in particular, is especially sensitive to proper or poor posture…For your body’s sake…it is essential to practice proper posture as much as possible in all activities of daily life.”25 The American Chiropractic Association issued a policy statement that “…advises and recommends to the public that good posture in all age groups has a direct and significant impact on not only spinal biomechanics but on all bodily functions. Recognition of the interrelationship and interdependence of good posture to good health requires that an increased awareness be developed by the public regarding the necessity of developing good postural habits in order to assist the body in achieving and maintaining good health.”26 Posture is defined as the relative arrangement of the parts of the body to each other and to the environment. Typically, it is measured, as a person stands, by dropping a plumbline sideways from the tip of the ear to the ankle joint and looking at the alignment of body parts along this vertical line. Alignment is also observed from front and back views of the body. This all seems fine and good. But there are hidden quandaries. When people think about ‘good posture’ they often tend to think of something static and fixed. This is reinforced by how ‘posture’ is measured, putting a person in a relatively static position or taking a photograph and measuring the alignment of the parts. It is not that this type of measurement is not useful. It can be. However, the static measurement of posture has been combined with the view of posture as a static and fixed ‘thing’and a view of the human organism as a collection of parts to be dealt with separately. People may then try to impose this static, piecemeal picture on themselves or others by holding themselves in a way that cannot be maintained for long. Or they may try to improve their posture with exercises designed to improve parts of themselves, i.e., range of movement and strength of the back and abdominal muscles, which achieve only partial effects. This has gone along with a failure to recognize both the general and individual requirements for learning new postural habits. As Karen discovered, the end result has been an emphasis on specific exercises to improve everyday posture. Such exercises are not sufficient for changing the moment-to-moment posture that you use in your daily activities. Thus the frustration that many of us have when trying to ‘improve’ our posture. “Posture” and “movement” are not necessarily opposites. Even when you seem to be sitting or standing still, there are always some movements going on. The movements of breathing continue, as do the slight swaying or balancing movements that occur when you are standing quietly. Posture always involves movement or activity. Movement or activity always involves some posture. To acknowledge this relation between posture and movement, some people refer to static posture as your posture at rest. This roughly corresponds to sustained positions that we get into. Dynamic posture refers to your posture when you move. I coined the term “posture-movement” to make the interrelatedness of posture and movement explicit. Remembering this relation may lead to better posture-movement solutions. Half-Mast and Full-Sail Self-Care However, just being told to stay active or being given a sheet of generic instructions on exercise and posture is often not enough to take full advantage of the possibilities for self-care. I call this generic approach the ‘half-mast’ way. A sailboat cannot take advantage of the wind if its sail is not up completely. An approach to prevention cannot work well with cursory, surface efforts. By contrast, in this book I present a ‘full-sail’ way of posture-movement self-care. I provide you with the background you need for understanding your back problem and specific principles and methods you can apply to make full use of your potential for self-care. With my help in applying such methods, Karen no longer feels plagued by chronic pain. Although she has had recurrences, they are less frequent and less severe. Her back moves more easily and she no longer feels the fear that “it is made of glass and will shatter.” She is working out at a gym and has begun playing tennis and basketball again for the first time in eight years. “I was very skeptical when I met you,” she wrote to me. “I recall that my first few visits were filtered through my negative thought at the time, ‘What is this guy going to do for me?’ I’ve come to realize, it wasn’t what you did for me. It’s what you taught me to do for myself.” Possibilities Chapter 2 Notes 2. Deyo, p. 50 3. Deyo, p. 49 4. See article “Prevalence of Back Pain — By Quality of Study” which reports these figures from the study by R.C. Lawrence et al., “Estimates of the Prevalence of Arthritis and Selected Musculoskeletal Disorders in the United States.” 5. Deyo, p. 50 6. Deyo, p. 50-51 7. See Dana Greene’s “Abstracts That Discourage Treatment Based on Imaging Results Alone.” 8. Boden 9. See Deyo, p. 50 and the article by Cherkin et al., “Physician Variation In Diagnostic Testing For Low Back Pain.” 10. Waddell, p. 244 11. Waddell, p. 243 12. See “Major Sciatica Treatment Proves Ineffective In Landmark Randomized Trial,” reported in The Back Letter. Also see Deyo, pp. 51-52, as well as Bigos, et al., and the Royal College Guidelines. 13. See Bigos et al., under the subheading “Physical Agents and Modalities.” 14. Waddell, p. 398 15. McKenzie, The Lumbar Spine, p. 2 16. Deyo, p. 51 17. See J.A. Rizzo et al., “The Labor Productivity Effects of Chronic Backache in the United States.” 18. See Elaine Thomas et al., “Predicting Who Develops Chronic Low Back Pain in Primary Care: A Prospective Study.” “About 30% of patients [in a group of 180 patients studied] continued to have disabling back pain after 12 months.” 19. This study was reported on in “Acute Back Pain Benign But Frequently Persistent” in The Back Letter. Only 37% of patients studied reported complete pain relief in the study done by Reis and associates printed in “A New Look at Low Back Complaints in Primary Care” in Journal of Family Practice, 48 (4): 299-303 (1990) . 20. One study showed disabling recurrences at rates between 8% and 14% from 3 to 6 months after an initial episode. Recurrence rates were 20% to 35% between 6 to 22 months after an initial injury (see Timothy S. Cary, “Recurrence and Care Seeking After Acute Back Pain: Results of a Long-term Follow-up Study”). 21. See Deyo, p. 52. Also see Samanta and Beardsley’s article, “Low Back Pain: Which is the Best Way Forward?” and “Exercise Beneficial for Low Back Pain” in PT Bulletin, August 30, 1999. 22. See Deyo, p. 52. 23. Qtd. in “New UK Back Pain Guidelines” in The Back Letter 24. See The American Academy of Orthopaedic Surgeons, Low Back Pain, available at www.aaos.org under patient education: spine: patient education brochures. 25. See Moffat and Vickery, pp. 123-124. 26. See the American Chiropractic Association (ACA) “Policies On Public Health.” |
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