Back Pain Backlash

All that trekking on steep footpaths, the laboring with primitive tools, the lifting and bending and digging: To all appearances, the Himalayan nation of Nepal should be the world’s back pain capital.

“But it’s strange--hardly anyone complains about their back,” says Robert Anderson, a medical anthropologist at Mills College in Oakland who worked at a health clinic in rural Nepal in the early 1980s. “Some of the villagers walked for two days to visit the clinic. But they came to us for respiratory problems, diarrhea, eye problems” and other complaints.

Only when Anderson examined the patients more closely, and had a translator interview them, did the silence break.

“The prevalence of back pain was very high,” Anderson says. “But they simply considered it a fact of life and worked through it.”

And so it is, in many rural areas of developing nations around the world: plenty of pain, but people work through it. They have little choice, of course. There are not many back clinics or chiropractors promising to ease their ailments.

Yet easy access to medical care may actually contribute to epidemic backache rates in many industrialized countries, researchers now say. The availability of so many “treatments” implies that back pain is a specific medical condition that can be diagnosed and cured. Usually it’s not, they say, and expecting a cure may make the problem worse.

In the United States, for example, backaches are the second most common reason for doctor visits, after cold and flu symptoms. Eight in 10 adults will have a bout of back pain sometime in their lives, and most will have more than one, resulting, by some estimates, in more than $10 billion a year in disability and other costs. And yet for all our lumbar cushions, zero-gravity lounge chairs, electric back massagers and spinal self-help books, we’re still deeply dissatisfied with our back care.

“When something hurts, we want it fixed--and fast,” says Bill McCarberg, director of pain services at the Kaiser Permanente health plan in San Diego, “It’s very frustrating to visit the doctor and find out that, in most cases, we can’t solve the problem.”

It’s not for lack of trying. Through the years, doctors have prescribed everything from bed rest and traction to steroid injections and aggressive surgery to mend aching backs. But in a series of careful studies during the past decade, researchers at the University of Washington in Seattle have exposed most of these approaches as futile, and sometimes harmful. These findings have helped set in motion a rethinking of how back pain is treated and diagnosed.

“I think we can say with certainty now that bed rest and traction are a bad idea,” says Daniel Cherkin, a scientific investigator at the Center for Health Studies, a nonprofit research unit of the Group Health Cooperative, and a member of the Washington team. “They both weaken the muscles supporting the back and make the problem worse.”

Most researchers say that back surgery--a common treatment for nagging pain a generation ago--is now necessary only when someone has a tumor; a spinal fracture; a botched previous surgery; or severe leg pain because of clear nerve compression in the spine. That is to say, for as few as 2% to 5% of all back pain patients.

The message hasn’t gotten out to everybody, however. In the mid-1990s, Cherkin surveyed some 1,200 physicians, from family doctors to back surgeons, asking what they thought were the best treatments for lower back pain, the most common complaint. Their answers reflected the confusion and lack of guidelines for treatment. Some favored chiropractic, others steroid injections, still others clung to corsets and bed rest. The confusion about treatments, says Cherkin, reflects deeper uncertainly about what’s actually going on in the spine.

No simple stack of vertebrae, the spine is a dense corridor of nerves, mantled in cartilage and bone, sheathed in ligaments and muscle. Each of its 33 bony joints is separated by gel-filled fibrous pads called disks, and the whole intricate rigging could go wrong in any number of ways.

“That’s why there are something like 18 different names for the problems,” says McCarberg. “Doctors usually have no earthly idea what’s causing the problem, but that doesn’t mean we don’t want to provide some explanation.”

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As a rule, physicians tend to concentrate on the disks; a bulging, herniated, or “slipped” disk (the terms are interchangeable), for instance, is one that is pushing painfully against surrounding tissue. Chiropractors focus more often on the joints themselves, looking for vertebrae that are stuck or out of alignment. And physical therapists often suspect strains in the muscles or ligaments.

Certainly there has been no shortage of experts pronouncing that most back pain is due to “spinal instability,” or repetitive stress injury, fibromyalgia, even psychological problems. As Dr. Richard Deyo, who directs the University of Washington group, writes, “Back pain management historically has been a series of fads and fashions.”

The truth is that, in most cases, no one knows for sure what’s happening. And even the assistance of high-tech medical tests, such as MRIs, yield fewer clues that some doctors let on.

In 1994, doctors at Hoag Memorial Hospital Presbyterian in Newport Beach studied spinal MRIs of a wide range of people. The investigators found that damaged or bulging disks are not only common but also show up in half of people whose backs feel fine. “There’s so little evidence to grasp onto,” says Cherkin, “that each practitioner tends to understand the problem within the perspective of his or her own training.”

This confusion not only drives patients to distraction; it may actually exacerbate back pain, according to a 1998 study. While working for Prudential Healthcare, health researcher Carol McPhillips-Tangum conducted extensive interviews of 54 patients with chronic back pain. She hoped to learn what their expectations were of doctors and whether they were satisfied with their treatment. She found that nothing so exasperated patients as a non-diagnosis. It only caused them to insist more strongly on their problem.

One patient, Pamela Lloyd of Atlanta, told the researcher, “I know in my heart of hearts that at least three of these doctors felt that I wasn’t really in the kind of pain that I said I was in. They couldn’t understand why I kept on hurting, when all these things indicated that I should be better. Well, the reason is because it didn’t show up on all of their tests.”

The pain is real, all right, and it is often frightening. That’s why people talk of “wrenching” or “throwing out” their backs. It’s one of only a few afflictions that can make a perfectly fit, healthy young adult suddenly gimp about like Father Time.

All the same, say back specialists, a backache is usually no more serious than a headache, as unlikely as it seems at the time. Often, it is the patient’s insistence on a diagnosis and cure that can turn it into a medical condition that feels more disabling.

“I think people get scared when they don’t get a diagnosis,” says Cherkin. “They are afraid to move, when the best medicine is to resume normal activity. What we say is, ‘Hurt does not mean harm.’ It’s completely counterintuitive, but it works.”

The good news, specialists say, is that there are plenty of things you can do to reduce--if not banish--the hurt. The key is getting pain relief early. Like many specialists, McCarberg starts patients with pain relievers; then muscle relaxants, if necessary; and if they’re not better after a week, he tries steroid shots in the back.

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What’s more, some big insurers such as Kaiser and Aetna US Healthcare now encourage patients and doctors to try a variety of alternative treatments rather than more aggressive treatment. All of the following approaches can reduce pain, virtually without side effects, doctors say. And the treatments often are covered by health insurers:

* Chiropractic. Some 20 million people a year go to chiropractors, and they have their reasons. In several large-scale studies, chiropractic has proved effective in reducing pain, at least in the first week or so after it strikes. Practitioners typically isolate a vertebra near the source of the pain, then perform an adjustment--pushing the joint through its natural motion.

* Physical Therapy. Physical therapists use a variety of massage, stretching and postural techniques to strengthen the back and allow patients to cope with pain. Many therapists use something called the McKenzie Method, an exercise program that includes side-bending and rotation movements, usually done while lying on the back or stomach.

* Massage. The long, gliding, kneading strokes of Swedish massage can ease pain, as can deep tissue techniques. In people with chronic pain, says Cherkin, regular massage sessions not only soothed symptoms but allowed a return to normal activities.

Many back pain veterans also swear by acupuncture, yoga or specialized postural-balance programs, such as the Alexander Technique. “I think you should be pretty optimistic, if you have pain,” says Cherkin. “There are a lot of things out there to try, and everyone seems to respond to something.”

Still, the most important step may be to observe what Robert Anderson did in Nepal: If you don’t consider back pain a medical problem, it’s not one. A Scottish orthopedic surgeon named Gordon Waddell actually tracked reports of back pain throughout recorded history and documented an escalation after World War II, when doctors first began thinking of the pain as related to serious spinal injury. “Sadly,” wrote Waddell, “we must conclude that much of low back disability is iatrogenic [caused by medical treatment].”

Deyo himself quotes French novelist Marcel Proust: “For each ailment doctors cure with medication, as I’m told they occasionally succeed in doing, they produce 10 other ailments in healthy individuals by inoculating them with a pathogenic agent 1,000 times more virulent than all the microbes: the idea that they are ill.”

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THE SPINE

The backbone is a stack of 33 vertebrae separated by sponge-like disks, all shrink-wrapped in muscle. It surrounds and protects a dense corridor of nerves that extend to all parts of the body. Doctors divide the vertebral column into three main sections: the cervical, in the neck; the thoracic, the upper back; and the lumbar, or lower back.

SPINE MECHANICS

Most back pain tends to occur in the lumbar spine. There is considerable debate about the source of pain, and diagnosis may vary depending on the type of specialist consulted.

1) When thinking about the source of back pain, physicians tend to concentrate on the disks. A bulging, herniated or “slipped” disk (the terms are interchangeable) is one that is pushing painfully against surrounding tissue or nerves.

2) Chiropractors focus much more on the joints themselves, believing that vertebrae that are stuck or out of alignment cause most back trouble.

3) Physical therapists often suspect that strains of the muscles supporting the spine are the source of pain or stiffness.

THEORIES OF BACK PAIN AND COMMON TREATMENTS

Over the years, doctors have proposed a number of explanations of back pain, most of which presume a specific treatment.

THEORY

Spinal Instability. A doctor’s diagnosis that the spine has become mechanically unstable, usually due to degenerated disks.

TREATMENT

Spinal fusion, in which surgeon bolts together adjoining vertebrae, inserting bone graft in between.

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THEORY

Subluxation. Chiropractors’ belief that pain results from misaligned joints in the backbone.

TREATMENT

Chiropractic adjustment, a thrust to the spine to restore joints’ natural position and range of motion.

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THEORY

Fibromyalgia. Vaguely defined syndrome that causes pain and stiffness in numerous spots on the body, including the back.

TREATMENT

Trigger point injections, a series of steroid or anesthesia shots in tender spots along the spine.

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THEORY

Gate Theory. Concept that the brain can moderate pain sensation, perhaps through stimulation of pain-inhibiting nerves.

TREATMENT

Electrical nerve stimulation, in which electrodes are placed over the sore spot and deliver a low charge that masks pain signals.

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THEORY

Psychological Stress. Idea that trouble in coping with everyday anxieties can create actual physical pain and exaggerate soreness.

TREATMENT

Talk therapy that teaches how to identify sources of emotional stress and better respond to them.

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Source: Drs. Richard A. Deyo, William R. Phillips