low back pain

Sunday, August 25, 2013

If the Nielsen ratings hold true, millions of people will have watched Tiger Woods drop to his knees immediately after his swing on the 13th hole, grimacing in pain because of back spasms. He rose stiffly, walked down the fairway slowly and eventually completed his round. Golf fans around the world will also watch to see what tests are done and what treatments are performed. It’s likely that Tiger’s care will waver from recommended guidelines and his name may come up in conversations between doctor and patient: “but Tiger got scanned and was prescribed medications, why not me?”

It is not often that the cause of back pain is caught on camera. Usually, the pain has a gradual onset, though there can be specific events that the patient can remember: the twisting to pick up a child, the leaning over at work, the reach to get something off the top shelf. Back pain is one of the most common reasons people seek medical advice and it is important that the doctor and patient are on the same page. Most often, the cause of low back pain is musculoskeletal, meaning that the pain is due to a muscle strain or a ligament sprain and there are two issues to be addressed. The first is to insure that the pain is due to a strain or sprain and nothing worse. The second is pain control so that the patient can return to daily activities.

In assessing the patient with low back pain, it’s important to make certain that there is no nerve damage or inflammation. Sciatica is most common, where the large nerve that originates in the low back, runs into the buttock and down the leg becomes inflamed. The irritation may be due to muscle spasm, a bulging or ruptured disk or bony changes including arthritis. In addition, other bone related problems can cause the pain, from compression fractures due to osteoporosis to cancer that has spread to bone. The diagnosis happens because the doctor talks to the patient and performs a physical examination. If there is concern about nerve damage, the test of choice is MRI not plain x-rays or CT scan. And an MRI is not needed if an operation or nerve injection is not contemplated.

Pain control is sometimes a contentious issue between patient and doctor. Guidelines recommend the use of over the counter pain medications like acetaminophen (Tylenol) or anti-inflammatories like ibuprofen (Motrin, Advil). Back exercises, manipulation, massage, acupuncture and yoga may all have their place. The problem is that patients want their pain resolved immediately and guidelines developed by pain specialists and primary care doctors suggest that it takes a few days for a sprain or strain to run its course and self-care with exercises, stretching, ice and heat and a little Tylenol should be all that is needed.

But if Tiger Woods gets an MRI, immediate physical therapy, narcotics and muscle relaxants so that he can play in 5 days, why can’t everybody else? And here is the dilemma that can face the doctor. Many clinics and hospitals use patient satisfaction surveys to assess doctor performance. How do you make patients happy but not give them what they have come to expect? Patients are very willing to learn why their body hurts and what the action plan will be. However, the doctor has to be willing to teach and that takes time. It may be easier for the doctor to order a test or write a prescription that isn’t needed instead of facing a potential confrontation with a patient or their family.

According to recent studies from Harvard Medical School, the care provided for low back pain has changed in the past ten years and not for the better. More than 11% of patients are getting MRI scans of their back, a 50% increase. Recommendations for patients to take acetaminophen or ibuprofen dropped from 37% to 25% while the number of narcotic prescriptions increased from 19% to 29%. (The increased use of narcotics is especially sad. Thousands of people die each year because of narcotic overdose and abuse.) Treatment guidelines are not being followed, more patients are being referred to surgeons instead of physical therapists and chiropractors and people are not being taught how to prevent back pain.

It’s unlikely that the people of the United States have become wimpier and unable to tolerate their back symptoms, but perhaps they have become more impatient. Time heals many things in the body and this is especially true for the back. A couple of weeks of ice, heat and stretching are often enough to get the body back together. Preventing the next episode will take longer. Weight loss, improved core strength and increased flexibility all take time and sometimes the guidance of a physical therapist, trainer or chiropractor.

It is easy to empathize with a pro athlete with an injured back. It’s less easy to accept that their care is different than the rest of the world; not better, not worse, just different.

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