Before finding a remedy, you need to know what's causing the backache


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Your back aches. What treatment or treatments will give you the most relief? That depends mostly on what's causing your back to ache.

Physicians classify lumbago, as low back pain is formally known, by how long it lasts and by its origin.

If you have low back pain for only a few days or weeks, it's acute. If your symptoms go away and come back again, it's recurrent. If pain persists for three months or longer, it's chronic.

About 60 percent of those who suffer from acute back pain recover in six weeks or less, but most who have acute back pain will have at least one recurrence.

Muscle and ligament strains and sprains are the cause of most acute back pain. Acute back pain usually gets better without any medical treatment.

For fewer than 10 percent of sufferers, back pain is chronic. But the causes of chronic low back pain tend to be more serious, and the simple remedies that alleviate pain from muscle and ligament strains don't work as well. A recent discovery by Danish scientists, confirmed by British doctors and published in April's European Spine Journal, found that up to 40 percent of chronic low back pain is caused by infection. This could revolutionize treatment and provide relief for millions.

The three general categories of low back pain by point of origin are mechanical, non-mechanical spinal problems and referred pain from internal organs. Mechanical pain is that emanating from a problem with a muscle or ligament (a strain or tear). Non-mechanical pain is essentially pain associated with a problem with the spine.

More than 90 percent of lumbago cases are mechanical, and about two-thirds of these are muscle and ligament strains and tears. About 90 percent heal without surgery or other invasive treatments.

Among the non-mechanical spinal problems that cause low back pain are neoplastic disease (tumors on the spine), inflammatory conditions such as spondyloarthritis (arthritis of the spine) and infections.

Referred pain from internal organs comes mostly from gastrointestinal diseases such as pancreatitis (inflammation of the pancreas, the large gland behind the stomach that releases enzymes to aid in digestion and hormones to help regulate how the body stores food), and cholecystitis (inflammation of the gall bladder, a small organ near the liver that also aids in the digestion of food), and from renal (kidney) failure.

Consumer Reports magazine asked more than 14,000 of its subscribers who said they'd experienced back pain in the last year to rate 23 different treatments. On average, each subscriber had tried five or six.

Hands-on solutions worked best, they said. Chiropractic treatments were favored by 58 percent of respondents, massage by 48 percent, physical therapy by 46 percent.

Manipulation of the spine eases back pain by restoring to their normal position the spinal bones that house the nerves, said Raymond Vactor, director of Wexford Chiropractic in Pine and host of radio program "Quantum Health" on WKHB-AM (620). "When these bones are out of place, they can irritate or put damaging pressure on the spinal nerves, which impairs the function of the nervous system."

Massage improves circulation of the blood, which speeds recovery of muscles made sore by overexertion. And massage increases release of endorphins, the body's natural pain medication.

"Massage lessened lower back pain, depression and anxiety and improved sleep," a 2001 study by the Touch Research Institute of the University of Miami (Fla.) found.

Physical therapists apply heat, cold and electrical stimulation to sore muscles and lead patients through specific exercises to strengthen the muscles of the lower back. The stronger these muscles are, the less the strain on the disks and joints of the spine. Physical therapy is recommended especially for patients who are recovering from, or who are about to have, back surgery.

Almost 70 percent of the subscribers said they took an over-the-counter medication such as Motrin, Aleve or Tylenol, but only 22 percent said these were very helpful.

Ibuprofen (Motrin) and naproxen (Aleve) keep injured cells from making or releasing prostaglandins, which cause pain and swelling. Acetaminophen (Tylenol) blocks in the brain the pain signals prostaglandins send.

A third of respondents said they took prescription medications, with 45 percent rating them as beneficial. The prescription medicines most often prescribed are more potent anti-inflammatory drugs such as celecoxib (Celebrex) and muscle relaxants.

In a 2011 survey conducted for the American Physical Therapy Association, 72 percent of respondents said they took either prescription or over-the-counter medications, 55 percent said they used heat (to warm up sore muscles before exercise) and cold (to soothe sore muscles after exertion) packs at home.

In the Consumer Reports survey, 59 percent of respondents said they were pleased with the treatment they received from a chiropractor, 55 percent with the treatment from a physical therapist, 53 percent with the treatment from an acupuncturist.

Physicians didn't fare so well. Only 44 percent said they were satisfied with the treatment they received from a specialist, just 34 percent were satisfied with how their primary care doctor treated them.

That's because for most who suffer from low back pain, seeing a primary care physician as a first provider can be a frustrating experience, said Michael Schneider, an assistant professor in University of Pittsburgh's department of physical therapy and the American Chiropractic Association's 2013 Researcher of the Year.

Primary care physicians receive relatively little training in musculoskeletal problems, he said. Their typical response to a patient who complains of low back pain is to write a prescription for a medication that can temporarily ease the pain but does not treat underlying mechanical causes, such as poor posture and muscle imbalances.

"People are not happy with a chemical solution to a mechanical problem," Mr. Schneider said.

For the roughly 90 percent of low back pain sufferers with non-serious mechanical back pain, the right person to see initially is a chiropractor or a physical therapist who specializes in musculoskeletal issues, he said.

More people would get the right treatment faster if there were diagnosis centers for low back pain as there are for diabetes and other major medical problems, the Pitt researcher said. And treatment would cost much less if initial diagnoses were made by advanced practice professionals who are not physicians.

"When you come into a primary care clinic with a cold, the first person you often see is a nurse practitioner," he said. "Only if there is an indication of something more serious is the problem kicked up to a doctor. That's how it should work for low back pain unless a chiropractor or a physical therapist is doing the initial assessment. Most of the time, treatment doesn't involve surgery or other major medical intervention."

In January 2012, UPMC changed its insurance standards for low back pain to put more emphasis on non-surgical treatments provided by chiropractors and physical therapists, such as exercise and rehabilitation.

The change was made both to cut costs and because "of the evidence that conservative therapy works best but hasn't been given as much attention as it deserves from the medical community," said Michael Parkinson, senior medical director of the UPMC Health Plan.

A key feature is to bundle, and thereby greatly reduce, copays for physical therapy, so cost won't keep patients who would benefit from physical therapy from receiving it, he said.

Since the change was instituted, back surgeries have been reduced by 25 percent, which "probably saved more than $1 million," Dr. Parkinson said.

But in the most serious cases, only a doctor will do.

health

Jack Kelly: jkelly@post-gazette.com or 412-263-1476.


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