Back pain

In many cases, it is not necessary to see a doctor for back pain because pain usually goes away without treatment. However, an individual should see a doctor if they experience numbness or tingling, severe pain, or pain that does not improve with medication and rest. Also, individuals should see a doctor if they have pain after a fall or an injury. It is also important to see a doctor if pain occurs along with any of the following problems: trouble urinating; weakness, pain, or numbness in the legs; fever; or unintentional weight loss. Such symptoms could signal a serious medical condition that requires treatment.

Applying ice as soon as possible during the 48 hours after straining a muscle can reduce pain. Ice slows inflammation and swelling, numbs soft tissue, and slows nerve impulses in the injured area. After spasms and acute pain subside, heat can be applied to loosen tight muscles. Over-the-counter (OTC) pain-relieving medications, such as acetaminophen (Tylenol®), ibuprofen (Advil®), or naproxen (Aleve®), may be used for short-term (less than two weeks). Two or three days of bed rest followed by a gradual return to normal activity is sometimes recommended.

Physical therapy and exercise: A physical therapist may apply a variety of treatments (such as heat, ice, ultrasound, electrical stimulation, and muscle release techniques) to the back muscles and soft tissues to reduce pain. As pain improves, the physical therapist can teach the individual specific exercises to increase flexibility, strengthen the back and abdominal muscles, and improve posture. Regular use of these techniques may help prevent pain from coming back. Exercise can correct current back problems, help prevent new ones, and relieve back pain, particularly after an injury. Exercise also strengthens bones and reduces the risk of falls and injuries.

Prescription medications: A doctor may prescribe non-steroidal anti-inflammatory drugs (such as flurbiprofen or Ansaid® and celexocib or Celebrex®), muscle relaxants (such as cyclobenzaprine or Flexeril®), and narcotic pain relievers (such as hydrocodone or Lortab®). A skin patch containing an opioid called transdermal fentanyl (Duragesic®) may relieve chronic back pain more effectively than oral opioid drugs. Muscle relaxants, opiate agonists, and narcotic pain relievers may cause drowsiness. Narcotic pain relievers may also cause physical dependence and should be used with caution. Corticosteroid injections (steroids, such as dexamethasone or Decadron®) may be used if pain-relieving and anti-inflammatory medications do not offer relief. The long-term use of steroid medications can cause complications such as weakened immune systems and swelling.

Tricyclic antidepressants, such as amitriptyline (Elavil®) and nortriptyline (Pamelor®), may be used for numbness, burning, aching, throbbing, or stabbing pains that shoot down the limbs. Side effects of these drugs include drowsiness, dry mouth, blurred vision, and constipation.

Surgery: Few individuals need surgery for back pain. Surgery is usually reserved for pain caused by a herniated disk. If the individual is experiencing unrelenting pain that is unable to be relieved by medications or progressive muscle weakness caused by nerve compression, surgery may be beneficial.

Disc removal: There are three common types of surgeries that involve the removal of damaged or herniated discs in the spine, including laminotomy, laminectomy, and disectomy. A laminotomy is the surgical removal of part of the lamina (bony arch) above and below an affected nerve. A laminectomy consists of the surgical removal of most of the lamina of a vertebra. A laminectomy is most often performed when back pain fails to improve with more conservative medical treatments such as pain medications and physical therapy. A discectomy is the surgical removal or partial removal of a spinal disk.

Fusion surgery: Fusion surgery involves joining two vertebrae to eliminate painful movement. Recovery following fusion surgery generally takes longer compared to other types of spinal surgery. Patients typically stay in the hospital for three or four days, but a longer stay after more extensive surgery is not uncommon. A short stay in a rehabilitation unit after release from the hospital is often recommended for patients who have had extensive surgery, or for elderly or debilitated patients. Pain from surgery varies.

Intradiscal electrothermal therapy (IDET): In intradiscal electrothermal therapy (IDET), doctors insert a needle through a catheter into the damaged spinal disk. The needle is heated to a high temperature for up to 20 minutes. The heat thickens and seals the disk wall, reducing disk bulge and the related spinal nerve irritation. It is unclear whether this treatment is effective for back pain.

Implanted pumps: Pumps may be implanted into the spinal area to deliver a constant flow of pain-relieving medications (such as opiates like morphine). Surgically implanted spinal cord stimulators modulate the pain response so that the individual with a back condition experiences less pain. The implantation may put the individual at an increased risk for infection.

Good scientific evidence :

Chiropractic: Chiropractic is a healthcare discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Multiple clinical studies have examined the effects of spinal manipulation in patients with acute or chronic neck pain. Overall, the quality of studies has been poor, and reviews of this topic have been unable to form clear or convincing conclusions. Better quality clinical research for the use of chiropractic for neck pain is necessary before a firm conclusion can be drawn. Although chiropractic helps many people with back pain (including lower back pain), there is not enough reliable scientific evidence to conclude whether chiropractic techniques are beneficial in the management of back pain when compared to conventional approaches, such as medication and surgery. Chiropractic has also been studied in lumbar disc herniation and whiplash injuries, with mixed results.

Devil's claw: Devil's claw (Harpagophytum procumbens) has traditionally been used as an anti-inflammatory and pain reliever for joint diseases, back pain, and headache. There are several human studies that support the use of devil's claw for the treatment of low back pain. However, most studies have been small with flaws in their designs, and many have been done by the same authors. Therefore, although these results can be considered promising early evidence, additional well-designed trials are necessary before a firm conclusion can be reached. It is not clear how devil's claw compares to other therapies for back pain. Devil's claw may lower blood sugar levels. A qualified healthcare provider should monitor patients taking drugs for diabetes by mouth or insulin closely. Medication adjustments may be necessary. Devil's claw may increase stomach acidity and therefore may interact with drugs used to decrease the amount of acid in the stomach, such as antacids, sucralfate, ranitidine (Zantac®), and esomeprazole (Nexium®).

Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. Several small controlled clinical trials report that regular use of hot whirlpool baths with massaging jets decreases the duration and severity of back pain when added to standard therapy, compared to standard therapy alone. It is not clear if there is a reduced need for pain control drugs, or if benefits are long-standing. Because these studies are small with flaws in design and reporting, better quality research is necessary before a strong conclusion can be drawn.

White willow: White willow (Salix alba) bark has been compared to cyclooxygenase-2 inhibitors (COX-2, commonly used for back pain and arthritis), and many of the studies found willow bark to be as effective or superior to other methods. Cost effectiveness studies have also been performed between white willow bark and conventional treatment; they found that willow bark was more cost effective. Additional study in humans is needed.

Unclear or conflicting scientific evidence :

Acupressure, Shiatsu: The practice of applying finger pressure to specific acupoints (energy points) throughout the body has been used in China since 2000 B.C. Shiatsu technique can incorporate palm pressure, stretching, massaging, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck/shoulder and lower back problems, arthritis, depression, and anxiety. One clinical study reported that acupressure was effective in reducing low back pain in terms of disability, pain scores, and functional status. The benefit was sustained for six months. More research is needed.

Acupuncture: Evidence is inconsistent regarding the effects of acupuncture in back pain. The research on acupuncture for neck pain and cervical myofascial pain also shows mixed results. Additionally, early study does not show that laser acupuncture is any more effective than sham laser acupuncture when used in combination with drugs and other mobilization therapies. Further human research is needed.

Alexander technique: The Alexander technique is an educational program that teaches movement patterns and postures with an aim to improve coordination and balance, reduce tension, relieve pain, alleviate fatigue, improve various medical conditions, and promote well-being. There is limited evidence in this area, and no firm conclusion can be drawn based on scientific research.

Healing touch: One poor quality, clinical study using 20 participants with chronic low-back pain suggested that healing touch may significantly decrease pain, improve range of motion, and improve orthopedic measurements. However, more research using healing touch for back pain needs to be performed before a conclusion can be drawn.

Magnet therapy: The use of permanent or harnessed bipolar magnets in the treatment of chronic back pain is controversial. Early evidence with stronger magnets (up to 2,000 gauss strength) reported benefits, while more recent study with lower strength (450 gauss strength) noted no effects. Additional research is necessary in this area before a firm conclusion can be drawn.

Massage: Several human trials report temporary improvements in low back pain with various massage methods. A clinical study reported slightly more efficacy for traditional therapy such as pain medications and surgery. However, the additional benefits of massage may contribute to its value for holistic nursing practice. Further research is necessary.

Meditation: Various forms of meditation have been practiced for thousands of years throughout the world, with many techniques originating in Eastern religious practices. Based on preliminary research, patients suffering from chronic low back pain may improve with breath therapy. Further clinical research is needed to confirm these results.

TENS: Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Electrodes are temporarily attached with paste in various patterns, depending on the specific condition and treatment goals. The effects of TENS or acupuncture-like TENS on low back pain remain controversial, and multiple controlled trials have been published in this area. Studies have not been consistent in the type of TENS techniques used (location, intensity, frequency, duration) or in definitions of back pain, and most trials have not been well designed or reported. Published meta-analyses have grouped some of these studies together to try to determine whether this technique is effective, but have also yielded inconsistent results, with some authors reporting overall benefits, and others finding no clear advantage over placebo. Better-designed research is needed before a firm conclusion can be reached.

Trigger point therapy: Trigger points are discrete, focal, hyperirritable spots located in skeletal muscle. The spots may be painful on compression and associated with pain and tenderness, motor dysfunction, and autonomic nervous system phenomena. The goal of trigger point therapy for back pain is to eliminate the trigger points, and thus lessen the pain. There have been few studies that addressed the therapeutic potential of this therapy. Overall, the evidence is positive and demonstrates that this therapy might be effective for the treatment of back pain. However, because back pain may be insidious and brought on by unrecognized causes, future studies should address trigger point therapy in various causes of back pain.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian (Hindu) philosophy. Preliminary research reports that yoga may improve chronic low back pain in humans. However, larger, better-designed studies are needed before a firm conclusion can be drawn.

Fair or negative scientific evidence :

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. Reflexology is often used with the intention to relieve stress or prevent/treat physical disorders. Pressure may also be applied to the hands or ears. A large trial comparing reflexology to relaxation or no therapy reports that reflexology is not effective for managing chronic lower back pain.

Historical or theoretical uses lacking sufficient evidence :

Integrative therapies used in back pain or related conditions that have historical or theoretical uses but lack sufficient clinical evidence include: homeopathic aconite (Aconitum napellus), alizarin (1,2- dihydroxyathraquinones), homeopathic arnica (Arnica montana), aromatherapy, bacopa (Bacopa monnieri), black cohosh (Actaea racemosa), bromelain, chamomile (Matricaria recutita, Chamaemelum nobile), detoxification therapy (cleansing), dong quai (Angelica sinensis), glucosamine, homeopathic nux vomica (Strychnos nux-vomica), and spiritual healing.

Proper body mechanics: Many options exist for individuals wishing to prevent back and neck pain. Learning proper body mechanics, such as bending, lifting, and twisting, is particularly important if the individual's occupation involves repetitive bending, lifting, and twisting, as is the case with athletes and construction workers.

Exercise: Regular exercise helps to keep back muscles strong and flexible. Regular low-impact aerobic activities do not strain or jolt the back and neck. Low-impact aerobic exercises may also increase strength and endurance in the back and allow the muscles to function better. Walking and swimming are also recommended by health professional. Abdominal and back muscle exercises, also called core-strengthening exercises, help condition back muscles so that they function more efficiently and help protect the back from injury. Flexibility in the hips and upper legs aligns the pelvic bones to improve back comfort. A healthcare professional can help the individual choose the best exercise program.

Posture: Maintaining good posture, such as sitting straight in a chair and not slumping, can prevent and decrease back pain. Individuals with jobs that require long standing or sitting should take frequent breaks from standing or sitting positions to help prevent back pain.

Weight control: Maintaining weight within an ideal range for the individual's body size is very important. Excess weight has been directly linked with the development and worsening of back pain.

Diet: Eating a healthy diet is important to prevent back pain. A healthy diet, including fresh fruits and vegetables, provides the body with essential nutrients for health.

Quitting smoking: Smokers have diminished oxygen levels in their spinal tissues that can hinder the healing process. Clinical studies have found mixed results on whether cigarette smoking leads to back conditions, but there is evidence that smoking may increase the risk of developing sciatica or back pain that radiates to the hip and/or leg due to pressure on a nerve.