Managing chronic low back pain

by Richard Glickman-Simon, MD

bp.1.gif If you never suffer from low back pain, consider yourself one of the fortunate few. Up to 85% of people living in industrialized countries will experience low back pain at some point in their lives, and 30% will say their backs hurt right now. Back pain is the most common reason for Americans under the age of 45 to limit their activity. It is the second most common reason for visits to the doctor, and the third most common cause of surgery.

There is some good news, though. With or without medical treatment, most people recover from an acute episode in a few days or weeks, and about 90% will be pain-free within three months. But for many people, low back pain becomes a chronic or recurrent condition, often resulting in considerable social and occupational disability.

Why so common?

Many factors contribute to low back pain—inadequate fitness, heavy lifting, poor posture. But our evolutionary history is to blame for our susceptibility to this pain. At some point in the distant past, some of our ancestors decided to stand on two feet, presumably so their hands would be free to fashion tools and use them efficiently. While their reasons were good, going vertical was not without its drawbacks.

Walking around on all fours distributes the force of gravity evenly over the length of the spine. Standing up, however, concentrates this force in one location—the lumbosacral region, just north of the buttocks. Our vulnerability to low back pain is the price we pay for bipedal locomotion.

Several factors can contribute to persistent back pain, including:
  • Work-related injury, particularly if the workplace does not provide the proper ergonomic environment
  • Structural abnormalities or injuries:
    • Scoliosis (curvature of the spine)
    • Intervertebral disk disease, which often results in a slipped disk

No obvious cause

Most cases of chronic back pain are idiopathic, meaning they have no clear explanation. Without a known cause, treatment is very difficult and often unsuccessful. This leads many people to alternative therapies. Among the most commonly used therapies to treat chronic low back pain are:
  • Chiropractic
  • Acupuncture
  • Massage
There is some evidence that, at least in the short-term, each of these therapies may be effective at alleviating discomfort, improving function, and/or enhancing a sense of well-being. However, it is unclear if any one of them is superior to the other or to physical therapy, the standard conventional treatment.

More is better

So what then is the best treatment for chronic low back pain?

According to recent evidence, what seems to matter is not which one, but how many treatments you use. In a careful review of 10 studies totaling 1,964 subjects with low back pain, researchers found that intensive multidisciplinary biopsychosocial rehabilitation (MBR) was significantly better at restoring function and reducing pain than single-disciplinary approaches.

In other words, interventions that addressed not only the physical aspects of the pain, but also its psychological, social, and occupational influences, were the most effective. Biopsychosocial rehabilitation programs include:
  • Cognitive-behavioral therapy
  • Massage
  • Exercise
  • Relaxation
  • Hydrotherapy
  • Transcutaneous nerve stimulation (low energy electrical impulses delivered to nerves in the back)
  • Heat and cold application

Complex solutions for complex problems

This combination of therapies makes a lot of sense. It is well known that an enormously complex range of factors, affecting many aspects of life, contribute to our experience of chronic pain. It is hard to imagine, then, that any single intervention—alternative or conventional—could succeed. An alternative therapy, therefore, should be part of a multidimensional treatment strategy.

Some people are skeptical of this comprehensive approach. Many patients, doctors, and health insurers prefer the path of quick fixes, like medications, that tend to control the pain rather than confront its underlying causes. Some programs like MBR are effort-intensive, time-consuming, and expensive at the outset. But, if they are successful, they have great potential to permanently restore function and enhance quality of life.

Where do we go from here?

If you suffer from idiopathic chronic pain anywhere in your body consider the following steps:
  • Recognize that your condition is a complicated problem that cannot be treated in isolation. This is the first step to gaining control over your pain and your life.
  • Determine which facets of your pain have not been adequately addressed—psychological, social, occupational, and/or physical. Tackling this problem from only one perspective is unlikely to work.
  • Continue working with your primary care physician. He or she is in the best position to coordinate a comprehensive, multidisciplinary treatment plan, whether or not it includes alternative therapies.
  • Strive for restore function. Your goal should be to resume your normal activities, not only to reduce your pain. Although the two are closely linked, the evidence suggests that focusing on function is the key to recovery.
  • Look both ways. Look ahead to visualize what it will be like to have no pain or disability. But also look back to measure your progress. It is easier to succeed when you see how far youve come.