Primary Care

When patients have back pain: Identify cause, intervene carefully

How to treat back pain depends to a large extent on the chronicity of the problem, says expert John C. Licciardone, DO.

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Americans spend approximately $50 billion each year on back pain, the leading cause of work-related disability and second most common neurological ailment (behind only headaches), reports the National Institute of Neurological Disorders and Stroke. But despite back pain’s prevalence, primary care physicians tend not to accurately identify its root causes or prescribe optimal interventions, say DOs with expertise in physical medicine and rehabilitation, pain management and osteopathic manipulative medicine.

“Primary care physicians are usually in a hurry,” notes physiatrist Daniel A. Brzusek, DO, who practices in Bellevue, Wash. “They have so many patients with runny noses, and they put musculoskeletal pain in the same box.

“You have to schedule back pain patients differently—10 minutes is not enough time. You need to schedule a minimum of half an hour.”

During that lengthy visit, physicians need to take a thorough history and not assume that the cause of a patient’s back pain is a sprain or strain, Dr. Brzusek suggests. Because of the reciprocal relationship between stress and pain symptoms, primary care doctors should ask questions about the patient’s emotional state, he says.

“ ‘How is your relationship with your significant other going? Are you happy with your job? Are you happy with your boss?’ These are among the questions that you need to ask,” Dr. Brzusek says.

Next, DOs need to perform a comprehensive physical and neurological exam, drawing on their extensive palpatory diagnosis training, says pain management specialist Douglas J. Jorgensen, DO, of Manchester, Maine.

“The first thing is to determine what the pathology is,” he says. “The etiologies are not always musculoskeletal. As osteopathic physicians, we’re oftentimes so focused on that element that we have to force ourselves to look at everything else.”

A deep-tendon reflex examination can help physicians quickly narrow down the source of the problem, Dr. Jorgensen notes. He also recommends giving back-pain patients a sensory examination—evaluating such variables as response to light touch, pain and temperature, vibration sense, and two-point discrimination—to identify which dermatome levels are problematic. Each dermatome, or skin area, is supplied by a single spinal nerve.

When a patient says he or she has a lifting injury, Dr. Jorgensen always looks at the anterior aspect of the body. “Oftentimes there are injuries to the musculature in the pelvic or groin area that could be causing referred pain to the low back,” he says. “While patients could have a pulled muscle in their back or a disk issue, people typically lift with their abdominal muscles, and they are squeezing their abdomen when they lift. Because many Americans are not in good shape, rectus abdominis strain is a common lifting injury that we see.”

In addition to pinpointing injuries through palpatory diagnosis, Dr. Jorgensen has detected malignancies—including biliary, colon and renal cancer and even cardiac tumors—in patients with back pain.

When a patient has back pain from a musculoskeletal spasm, “the tissue feels tight and hard,” he says. “And it’s responsive. If you hit the right area, it grabs you because it’s a defensive reflex.”

But if the back pain is caused by an organ-system problem, the tissue will feel and behave differently, the reflex being viscerosomatic, Dr. Jorgensen explains. “The tissue will feel like thick, wet wood that’s just been drenched,” he says. “When you push on it, it’s firm but soft at the superficial aspect. And it won’t respond to articulatory techniques. And it will barely respond to myofascial techniques.”

Unless they suspect such severe pathology, neither Dr. Jorgensen nor Dr. Brzusek will order magnetic resonance imaging or an X-ray during the initial visit.

“An X-ray is only used if you can’t define the patient’s problem even after a lengthy history and comprehensive physical exam,” Dr. Brzusek says. “If you have to get an image just to find the pain, you’re going to fail, and an X-ray is going to be the wrong diagnostic tool to order.

“MRIs, on the other hand, should only be used if you are suspecting metastatic disease, tumors or a herniated disk with radiculopathy.”

Dr. Jorgensen remembers speaking once with a military physician who said he ordered an MRI for every patient with back pain. Such a protocol would be ridiculously cost-prohibitive and would likely lead to overtreatment, he says.

“The problem with ordering MRIs or any imaging for that matter, even X-rays, is that you may find pathology that is not related to the reason patients are seeing you,” Dr. Jorgensen says. “This is a discussion that keeps coming up in the medical world. We are spinning our wheels doing treatments that are unnecessary and potentially harmful.”

Acute versus chronic

How to treat back pain depends to a large extent on the chronicity of the problem, says John C. Licciardone, DO, the executive director of The Osteopathic Research Center at the University of North Texas Health Science Center in Fort Worth. Physicians need to determine whether a patient has acute, sub-acute or chronic back pain. Acute pain is new and may last up to four weeks. Chronic pain generally lasts at least three months. And subacute pain lies in between.

The thinking on acute back pain has changed considerably over the past decade, Dr. Licciardone says.

“People thought low back pain that came on suddenly would go away just as suddenly without much treatment involved,” he says. “And in some cases, that is what happens. For example, someone may have acute low back pain because they worked too hard in the garden. In that case, it is probably true that the patient just has to be careful for a few days, avoiding overuse and taking some over-the-counter medication.”

But acute back pain is also apt to indicate a significant injury or an underlying medical problem that requires imaging, Dr. Licciardone says, while ongoing, nonspecific low back pain is more likely to involve psychological stress or depression.

For patients with acute back pain who are not suspected of having a serious disease, Dr. Brzusek uses a combination of 400 mg of ibuprofen and 325 mg of acetaminophen every six hours. He also instructs these patients not to rest their back but to proceed with gentle range-of-motion exercises while applying ice. And he recommends swimming or at least exercising in a swimming pool.

“We really get our patients moving,” Dr. Brzusek says, noting that he has secured discounts for his patients at a nearby pool. “I get my patients into the pool immediately and have them walking in it. Within a week to 10 days, I have them in an aerobic exercise program in the pool.” After two weeks of this regimen, most acute back pain patients feel much better, he says.

While exercise, ice and over-the-counter analgesics or nonsteroidal anti-inflammatory drugs remain the cornerstone of the treatment protocol, Dr. Brzusek does step up to stronger interventions if necessary.

“We do surgery when indicated,” he says. “But patients have to pass a lot of litmus tests before we’ll do surgery.”

Dr. Brzusek notes that he rarely injects spines with corticosteroids or analgesics or uses prolotherapy, except for sacroiliac joint dysfunction. “I don’t believe in injecting spines unless I find some instability,” he says. “I find more instability in the sacroiliac joint than I do in the lumbar or cervical spine.”

Dr. Brzusek, who served on the committee that wrote Washington state’s guidelines for opiates, only prescribes them as a last resort for noncancer-related back pain. “Don’t prescribe narcotics,” he urges primary care physicians. “Instead, send patients with severe back pain that won’t go away to your local physiatrist.”

OMT effective for ongoing pain

For patients with subacute or chronic low back pain, osteopathic manipulative treatment has been shown to be effective, says Dr. Licciardone, the lead investigator of several published studies on the efficacy of OMT.

Today, chronic low back pain is considered a manageable condition similar to asthma, Dr. Licciardone notes. “In general, if people with asthma take the right medications, follow their doctor’s instructions and avoid the triggers, they’ll be fine,” he says. “But if they don’t, then they’ll have flare-ups of their asthma.

“It’s the same thing for people who are susceptible to chronic low back pain. If they are careful about what they do and perhaps use some medications judiciously, they’ll keep their pain under control. But if for some reason, they overexert themselves or do things that are stressful, then their low back pain will flare up.”

OMT patients more often realized moderate to substantial pain reduction compared to patients who received ultrasound therapy or sham OMT, according to Dr. Licciardone’s double-blind, randomized, sham-controlled trial published in the Annals of Family Medicine last year.

“The studies we’ve done in the past several years indicate that you can bring chronic low back pain under control with OMT,” Dr. Licciardone says. “By that, I mean substantial improvement—at least a 50% reduction from the original level of back pain. And you can bring the pain under control with as few as two to three treatments.”

Dr. Licciardone points out that patients who received OMT—any combination of six different techniques—used prescription medication less often during the course of the study. “What that tells us is they were getting better with the OMT, so they didn’t have to use their prescription medication for breakthrough pain,” Dr. Licciardone says.

But, in another study, patients who took over-the-counter medication in addition to OMT had even better outcomes. “If you can do so without having any serious adverse effects, it might be worthwhile, perhaps in a short-term regimen, to take over-the-counter medications to enhance the effect of OMT,” he says.

Raising the functionality bar

Dr. Jorgensen also views OMT as an important part of his armamentarium in treating patients for chronic back pain. “I’ve been doing manipulative medicine long enough that I can usually get someone 50% to 80% better in two to three visits,” he says.

But he typically uses OMT in conjunction with other modalities, such as exercise and medication. His goal, he stresses, is to help patients become functional rather than pain-free.

Patients must be encouraged to get out of bed each morning, do their exercises no matter how painful, and strive to engage in normal activities of daily living.

“I ask patients, ‘What are the top three things you want to do now that you can’t?’ ” he says. “They might say, ‘I want to be able to clean my house,’ ‘I want to be able to play cards on Thursday night’ or ‘I want to be able to sit at my grandson’s Little League game.’ ” As patients reach those goals, Dr. Jorgensen raises the bar.

“We try to get their functionality up as high as it can be,” he says.

When patients initially report their pain level at an eight or a nine on a 10-point scale, Dr. Jorgensen’s objective is to bring them down to a level four or five. “If I can get them down to the one-to-three range, that’s exceptional and it makes me very, very happy,” he says. “But working effectively with back pain patients means managing their expectations.”

2 comments

  1. Arthur E. Angove, D.O., General Surgeon, Ret.

    Thank you for this encouraging message. Throughout the years of my surgical practice I’ve used OMM to improve the length of stay in the hospital, and the patient’s return to normal living. As with any mental, physical or spiritual therapy, results vary, and the use of all three are necessary for a more rapid and complete healing; which is an osteopathic philosophy.

  2. Pingback: Good Snacks For Building Muscle – Muscle Building Bible

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