Why lower-back pain is so tough to treat

An interview with Scott Haldeman, M.D., Ph.D., D.C. First trained as a chiropractor, Haldeman received a Ph.D. in neurophysiology and then went to medical school and became a practicing neurologist. He is a clinical professor in the department of neurology at the University of California at Irvine and co-editor of the January/February 2008 issue of The Spine Journal. He is also a former president of the North American Spine Society.

Why do people with lower-back pain have so much trouble figuring out what to do?

First, everyone seems to be selling some kind of gimmick, treatment, or pill, but there is no magical cure. Second, there is no medical subspecialty that focuses on general spine care. As a result, every subspecialty has learned its one or two treatment techniques. You have multiple professionals who think they have the one answer. Finally, we don't have a good standard of care for lower-back pain. Everybody has different preferences. Where one person may respond well to acupuncture, another may do better with analgesics.

How do you sort through the options?

Navigating the selection of available, advertised, and commonly used treatment options without an informed guide is like shopping in a foreign supermarket without being able to read the product labels. There are more than 60 medications currently being offered to back-pain patients. There are well over 100 different manual techniques in chiropractic, physical therapy, osteopathy, and massage therapy. More than 20 different exercise programs exist. There are more than 9 educational and psychological therapies and more than 20 different injection therapies. In addition, there are a variety of minimally invasive interventions offered as an alternative to surgery, and many surgical approaches. Finally, there are a large number of lifestyle products such as braces and beds, and a constantly changing variety of complementary and alternative medical approaches.

Where's the right place for someone with lower-back pain to start?

The first step is to go to a noninvasive practitioner, such as a family physician working with a physical therapist or a chiropractor. The first thing that a doctor will do is rule out dangerous conditions such as infections or cancer, then figure out if you have "back pain alone" or "back pain plus." If you have lower-back pain alone, which is by far the case in the majority of people, you have a series of options. These include exercise, education, anti-inflammatory medications or mild analgesics, manipulation, manual therapy, mobilization, and possibly acupuncture. If you have acute "low-back pain plus," meaning you have nerve involvement or severe pain to the point where you can't get out of bed, you may require more intensive evaluation and treatment.

Why are chiropractors so popular?

They spend more time with you. People feel better when they go to chiropractors because manipulation or adjustments that are offered do provide relief. It's also worth noting that chiropractors tend to be nice people who take time with patients. Finally, they're relatively inexpensive.

Why is lower-back pain so difficult to treat?

For one thing, there is no single structural cause of lower-back pain. It's a multifactorial condition with physical, psychological, genetic, social, and general health components. Lower-back pain is worse in people who smoke, those who do certain types of physical activity, and in people with psychological distress.

What medications work best?

No one medication works better than any other, and with all medications, you have to weigh potential side effects. Most guidelines suggest acetaminophen (Tylenol and generic) as the first choice. It has a low complication rate and provides reasonable analgesia. The next-line medications are the nonsteroidal anti-inflammatory drugs (NSAIDs), such ibuprofen (Advil, Motrin IB, and generic), naproxen (Aleve and generic), and aspirin. Long-term use of opioids (codeine, morphine, or oxycodone) is probably not a good idea for treating lower-back pain, but the drugs may be needed for short-term pain relief if other treatments don't work.

I have chronic lower-back pain and degenerative changes. When my back flares up I generally take naproxen, and go either for massage or chiropractic treatment. I also try to go to the gym regularly. Studies that have been carried out suggest that no one exercise stands out as better than any other, but the amount of time you spend exercising is probably the most important factor, and it's recommended to increase it gradually and within your level of tolerance. A combination of cardiovascular exercise together with strengthening and mobilization exercises appears to be particularly important. I try to go to the gym at least three days a week and do one hour of cardio work, and alternate 15 minutes of abdominal/trunk exercises with 15 minutes of weights.