RECOVERING FROM CHRONIC BACK PAIN

                                                                  By David G. Schwartz, M.D.

     Acute and chronic back pain cause major suffering and cost in lost work time, productivity, and medical costs.  This disables 50 million Americans at a cost of $20-50 billion annually.  The number of physician visits is second only to colds and flu. 

     Dr. Douglas R. Johnson, M.D., Dr. Ronald D. Siegel, Psy.D.,  and Michael H. Urdang, in their book, Back Sense, Broadway Books, 2001, ISBN 0-7679-0636-5, present a novel recovery plan to “recapture a life free of back pain.”  To contact these authors, visit www.backsense.org.  

     For people with this chronic problem, it is recommended to read this book thoroughly to make the best of a recovery process, but this article gives an overview of how it works and reviews its supporting research data.   

     The authors make the point that “bad backs” are rare, and that most backs are strong and resilient and that most back pain is caused by muscle tension and stress.

     The program involves understanding the causes of back pain, some common misunderstandings, the emotional factors, mind/body reconditioning, and physical exercises.

     Before understanding how the program works, it is important to review the supporting research literature.

     In one study, each of 64% of people who had never suffered from serious back pain had an abnormal disc, 52% - a bulging disc, 28% - herniated disc, and 38% - more than one abnormal disc.  Many other abnormal spine structures were found in these pain-free individuals.  New England Journal of Medicine 331(2; July14, 1994): 69-73.

     Many people with chronic back pain show no abnormalities after extensive testing. New England Journal of Medicine 318(5; Feb 4, 1988): 291-300.  Many with abnormalities continue to have pain after successful surgery, and MRI’s done 1 year after surgery and at 10 years after surgery showed no relationship between the state of their disc and current pain level. Spine 19(2; Jan 15, 1994): 176-82, and 20(6; Mar 15, 1995): 710-14.  When no abnormality was discovered at surgery, relief from pain occurred half of the time, which result casts doubt on the term “successful” surgery, even when abnormalities are found and repaired. Acta Orthopaedica Scandinavica 142(Supp.; 1972): 1-95.

     Poor, rural farmers in developing countries who have much more hard physical labor, bumpy roads, and poor beds have much less back pain than people in the industrialized nations. Spine 22(15, Aug 1, 1997): 1747-54.  Back pain disability is rare in these developing countries.

     The incidence of serious medical causes from back pain is very low. US. Dept of Health and Human Services Clinical Practice Guideline # 14 Dec 1994.

     A systematic review of studies showed that normal activity is superior to rest for acute back pain. British Journal of General Practice 47(423; Oct, 1997): 647-52.  A multi-center trial showed vigorous exercise to be far superior to conventional treatment. Spine 15(6; June 1990): 514-21.  One study demonstrated that patients could improve physical capacity without increased pain, in spite of their belief that the exercises would cause more pain. Spine 17(9, Sept, 1992): 1060-64.  Several Studies revealed that back schools, back care education, and safety training had no benefit. New England Journal of Medicine 337 (5; July 31, 1997): 322-28, Spine 14(3; Mar, 1989): 338-44, Physical Therapy 67(9, Sept, 1987): 1375-83.

     If no serious medical problem is the cause of the back pain, it is usually the result of some kind of stress, and in chronic back pain, it usually is perpetuated by the fear of exercise-induced pain.  Manifestations of the stress can be frustration, job dissatisfaction, repressed anger, depression, anxiety, fear of more back pain, tension in back muscles, catastrophizing, over-generalizing, and lack of assertiveness.  The authors site many articles and studies demonstrating the role of these emotional and stress factors from British Journal of Medical Psychology, Journal of Consulting and Clinical Psychology, Perceptual and Motor Skills, Psychophysiology, Pain, Indian Journal of Clinical Psychology, Cognitive Therapy and Research, Scandinavian Journal of Behavioral Therapy, Journal of Behavioral Medicine, and Journal of Psychology.

     The authors also cite numerous studies showing that disability payments interfere with recovery from chronic back pain.  Spine 20(24; Dec 15, 1995): 2702-9, 22(17; Sept 1, 1997): 2016-24, Psychosomatics 15(4; 1974): 174-77, and Health Psychology 14(6; Nov, 1995): 537-47.

     The authors advise that serious medical cause of back pain, although uncommon, should be ruled out before beginning a program of recovery.  The physician may order blood and urine tests, X-Rays, MRI’s, EMG’s, etc. if serious causes are suspected.  Any of the following could be red flags for such conditions:  unexplained weight loss, fever, chills, recent urinary tract infection or other infection, immune suppression, recent major injury, history of cancer, pain that worsens lying down at night, history of osteoporosis, age less than 20 or more than 50, numbness in groin or buttocks, difficulties with urinating or controlling bowel function, or worsening extreme weakness in the legs.

     If no other serious medical problem is present, then it is recommended to undertake the recovery program.  This includes a gradual increase in physical activity, stress management, gradually defusing the fear of pain and the fear that activity will cause pain, sticking with a regular exercise schedule, tracking progress and rewarding success, increasing positive thoughts, decreasing worry, practicing mindfulness meditation, and doing other forms of relaxation training.  Mindfulness involves taking time to notice all sensations, feelings, activities going on around inside one’s own body and in the external environment, being aware of and accepting of all these sensations, sights, sounds, including the pains in the back, without trying to control, ignore, or brace against the pain.

     The most benefit can come from reading the book, taking time to design a self-help program, and getting a physical therapist or counselor for support through the process.  Massage, chiropractic, acupuncture, heat and cold, muscle relaxants, mild analgesics, all can be helpful, but by themselves they do nothing for long term success if they are not followed immediately by or coupled with stretching exercise and other physical activity.

     Physical activity and gradual return to normal activities is the hallmark of the program.  All the other therapeutic measures just help make that happen.  This is based on the premise that the back is strong, not fragile, and one needs not be afraid of using it.  In many cases the authors found that physical exercise by itself was successful even without the stress management program.  This may have worked because physical activity by itself releases stress and builds confidence.

     If this program is followed, it can bring new hope to enormous numbers of people who have been suffering from disability, depression, and pain, and it can allow them to reclaim their active, productive lives.