Managing Low Back Pain Without Medications
There are a wide variety of treatment options available for the patient with low back pain that don't rely on medications. There's spinal manipulation, acupuncture, massage, nerve stimulation, biofeedback, yoga, behavioral counseling, lumbar supports, and much, much more. This article is designed to assist physicians and patients in understanding what's out there and how and when to use it.
It's clear that most low back pain is not life-threatening. It might hurt but it won't harm you. It is called self-limiting because it goes away after a few days to weeks. The diagnosis is often nonspecific mechanical low back pain. That's a fancy way of saying, we don't really know exactly what's causing the problem. We just know it isn't a fracture, infection, tumor, or other serious pathologic process.
Specific treatment beyond staying active and modifying activities (don't do things that make it hurt!) isn't really needed. More and more research is pointing to depression as a major factor. But whether back pain is a symptom of depression or depression develops after back pain becomes chronic is still undecided.
When back pain persists beyond a couple of weeks up to a month further testing can be done to make sure there isn't something else going on. When testing has ruled out any serious underlying pathology, then what? Should the patient try chiropractic care? Physical therapy? A massage? Maybe acupuncture?
Well, this is where the evidence is lacking to help us direct and guide patients. Studies show that manipulation performed by a chiropractor or physical therapist can be helpful for acute low back pain. Massage and acupuncture also seem to have some benefit in terms of enhancing healing. Long-term effects are not as likely (i.e., these techniques don't prevent future episodes of back pain).
Physical therapists can often identify problems with posture, movement, and alignment that may contribute to the development and recurrence of low back pain. An individually designed rehab program can help restore spinal alignment, normal muscle function, and motor coordination. Many therapists combine traditional approaches with other physical modalities such as yoga, Pilates, and/or relaxation techniques to aid in recovery and then maintain spinal health.
What about those folks who just don't seem to get better no matter what they try? When that happens, it's time to go back to the drawing board. Physicians are encouraged to review the case for anything that might be missing. Taking a closer look at the patient's personal goals, activity limitations, work issues, attitudes, and beliefs might help pinpoint the next step.
Sometimes behavioral or psychologic help is needed. Catastrophizing or dramatizing life events (including pain) can lead to more intense pain that doesn't go away. Behavioral specialists are trained to help people literally change their minds -- change the way they think because these maladaptive thoughts are contributing to the persistence in painful symptoms.
People who start avoiding certain movements or stop moving to avoid any chance the pain will start up again are experiencing something called fear avoidance behaviors. That's another dimension to chronic back pain that must be addressed. Behavioral specialists working with physical therapists can help patients overcome this trigger for back pain.
When low back pain becomes chronic and many of these nonpharmacologic (without medication) techniques are tried but fail, then a team of specialists combine various approaches to create a multidisciplinary rehabilitation program. Medications for pain control and antidepressants may be used. A program of intense, graded activity and exercise supervised by a physical therapist is supported by behavioral counseling to help patients prepare mentally to cope with their pain and the intensity of the program.
There isnÃ¢â¬â¢t a one-size-fits-all approach to low back pain. But evidence from studies so far support clinical practice guidelines such as were outlined in this overview article focusing on nonpharmacologic treatment approaches. Patients must work with their physicians to find the program that works best for them and stick with it. When one approach doesn't seem to fit the bill, then it may be time to try another or to combine several methods together.
Patients need to be advised that acute low back pain is often self-limiting. Give it time and stay active. Rest may help in the first couple of days, but don't stay in bed. When acute pain doesn't go away with this approach and chronic pain develops instead, expect to work hard to overcome this problem.
A cure doesn't always take place. At that point, it becomes a matter of pain management. But patients can function and even regain a measure of quality of life when pain persists. Don't give in and don't give up. There are many alternative approaches that can help you stay active at home and at work -- despite the pain.
Steven J. Atlas, MD, MPH. Nonpharmacological Treatment for Low Back Pain. In The Journal of Musculoskeletal Medicine. January 2010. Vol. 27. No. 1. Pp. 20-27.