The stubbornness and aggravation of back pain afflicts an estimated 540 million people worldwide. At least 80% of Americans have complained of significant back pain at some point(s) in their lives. Severe back pain is the 5th most common reason for doctor visits in the US and 40% of all workplace absences are due to back issues. The following is the latest science on this persistent scourge.
The back is so complex there is often no specific area that can be repaired:
“But perhaps the most helpful thing we can do is challenge the assumption that, if our back hurts, there is a pain generator in there somewhere that can be scanned, identified, injected or surgically removed, and fixed. ‘That whole notion is erroneous,’ says Cathryn Jakobson Ramin (investigative journalist who exposed the US back industry). ‘The truth is that low back pain is a many-faceted problem, emerging from your life situation, the state of your body and the social factors surrounding you.’ Rather than trying to find a doctor who can make the pain disappear, we need to be aware that to a certain degree, it is a part of life and the best approach is to keep physically active in the right way, to find a strategy to manage stress and to keep on with normal activities. Like all complicated pain, avoiding it, trying to use a substance to blot it out, investing in one person the belief that he or she can cure you: that all makes it worse.”
Invasive back treatments such as injections and surgery are often unnecessary:
“(At) an American Academy of Orthopedic Surgeons conference in 2010, 100 surgeons were asked whether they would have surgery on their spine for nonspecific low back pain. The answer – from all but one – was ‘absolutely not’. Spinal fusion surgery, which is sometimes recommended when disc degeneration is identified on an MRI, is a procedure in which the offending disc is cut out and the surrounding vertebrae are re-connected, either with bone graft or with titanium screws and plates.
“At best, these spine surgeons define success as a 38% improvement in pain and function ….. but if a hip or a knee surgeon had a 38% success rate, that physician would no longer do that surgery.”
MRI scans that attempt to diagnose lower back pain may do more harm than good:
“When it comes to diagnosing most back pain, MRI machines are like Monty Python’s medical machinery that goes ‘bing.’ For back pain, MRI and X-ray are medical machines that make false alarms…..
“They don’t always make false alarms, of course. MRI is a miracle technology, no doubt about it — the ability to get clear images of soft tissues deep inside the body is valuable, and extremely tempting for everyone involved.MRI can shine when it’s actually needed and done well…..
“But the sad truth is that it’s not needed anywhere near as much as it is actually used, and it’s especially not needed for most low back pain. And not doing it well? That’s just normal: radiology reports are usually written without clinical context, and frequently presented to the patient like diagnoses. But low back pain experts have long understood that you simply cannot reliably diagnose low back pain with MRI or with X-ray in isolation — and trying to do so reliably raises false alarms that actually do harm. Premature MRI is actually often worse than useless.”
Drugs for back pain should be taken only after thoughtful consideration and consultation:
"NSAIDs (non-steroidal anti-inflammatory drugs) are often the go-to drugs for back pain relief. They can be purchased over the counter (or, in higher doses, by prescription) and include ibuprofen (Advil) and naproxen (Aleve).
“NSAIDs help reduce pain, swelling, and inflammation in muscles and around damaged spinal discs or arthritic joints. Acetaminophen (Tylenol) is also a pain reliever and often sold alongside NSAIDs, but it's not an NSAID and does not help with inflammation…..
“Because NSAIDs are easy to get, people tend to overuse them, which can expose them to possible side effects like stomach pain, ulcers, bleeding, or even kidney damage. There is no recommended standard dosage for NSAIDs for back pain. ‘Follow the guidelines on the label, and let your doctor know what you are taking and how much,’ says Dr. Shmerling (clinical chief of rheumatology at Harvard-affiliated Beth Israel Deaconess Medical Center).
“Keep in mind that NSAIDs might not always be the best medicine for back pain. A study published online Feb. 2, 2017, by Annals of the Rheumatic Diseases reviewed 35 placebo-controlled studies that included more than 6,000 people who had all sorts of spine-related pain, including neck pain, low back pain, and sciatica. While people who took NSAIDs had less pain and disability after starting treatment than before, the effect was quite small and similar to improvements reported by those who received a placebo.
“Also, those who took NSAIDs were two-and-a-half times more likely to experience side effects. ‘This doesn't mean that NSAIDs can't help you, but only that they don't work for everyone,’ says Dr. Shmerling.”
Opioids are not effective for non-surgical acute and chronic low back pain:
“Consequences of prescription opioid use involve harms, addiction, tolerance and death. Despite routine prescription, opioids are not recommended for initial intervention by any major multidisciplinary low back pain (LBP) guideline…..
“Opioids were not shown to be superior to other medications, and only showed superiority to placebo comparators (at cost of additional harms). This review identified trends of higher harms rates and higher percentages of severe harms in opioid arms for the management of sub-acute and chronic LBP. The majority of trials that demonstrated benefits with opioids also had potential conflicts of interest. Lastly, non-opioid medications demonstrated statistically significant pain improvement compared with opioids. We feel that the results of the trial are supportive of current LBP guidelines and do not condone the initial use of opioids in management of sub-acute or chronic LBP.”
Stem cell scam artists are already promising miracle “cures” for back problems:
“(This) investigation highlights the serious potential risks to patients of stem cell therapies administered for unapproved and unproven uses other than hematopoietic or immunologic reconstitution. Although the safety and efficacy of stem cells for other than hematopoietic or immunologic reconstitution have not been well established, many companies, clinics, and clinicians continue to market products from various sources as treatment for orthopedic, neurologic, and rheumatologic conditions without FDA approval.
“Such clinics and providers operate in outpatient settings, which often have less robust oversight of infection control measures, including injection safety and medication preparation, potentially amplifying risk to patients. Therefore, FDA has recommended that patients avoid receiving such products outside controlled clinical studies being conducted under an investigational new drug application; these settings help ensure that appropriate manufacturing and safety reporting procedures are followed.”
Smoking can only exacerbate back problems:
“The evidence is strong enough that ‘I think we can, with a fairly high degree of certainty, link smoking to multiple negative outcomes,’ says Dr. Crawford Barnett, a pain management specialist at Cleveland Clinic Hillcrest Hospital in Cleveland. Research finds that lighting up is linked to higher rates of osteoporosis, lumbar disc diseases – or those that affect the lower back – as well as increased problems with bone healing. And studies show those who smoke who suffer spine injuries or from other back problems that turn out to be short-term issues for some, tend to have a greater chance of going on to develop chronic pain as a result.”
Attitude and lifestyle are integral in dealing with back pain:
“Traditionally we have thought of pain as a signal transmitted from the periphery to the brain – such as when a finger touches a hot plate. This understanding of pain serves well for very brief acute pain; however, it is only a small part of the story when pain is longer lasting.
“Just as there are nerve tracts that carry pain signals upward to the brain, there are also tracts coming down from the brain that regulate the sensitivity of the spinal cord and thus determine how much pain we perceive. These tracts can amplify pain – making a trivial stimulation seem terrible – and can block it, which probably explains why quarterbacks and combat soldiers can carry out remarkable activities, and only after some time realize that they’ve been injured……..
“Psychological factors rarely seem to be an important cause of prolonged pain, but they invariably affect it – for better or for worse. Attention and vigilance account for much of the psychological modulation of pain. Pain that the brain thinks is important will be amplified, and those that it thinks are of no consequence will be lessened. (Just as a mother in a noisy New York apartment sleeps soundly as ambulances and car horns sound through the night, but awakens instantly when her baby whimpers.)
“Mood profoundly affects pain, and even something as simple as reading a short story that it either funny or tragic changes people’s thresholds and tolerance to experimental pain. Research over the last 35 years has demonstrated that pain, as well as numerous other factors, change the central nervous system in ways that lead to prolonged pain, even when the illness or injury that initiated it has healed. In fact, most chronic pain is more attributable to sensitization of the nervous system than to problems in the body parts that hurt……..
“Catastrophizing, the tendency to assume that the worst that can happen is true, has been shown to promote pain and dysfunction. In the case of back pain, a person whose thoughts tend to run in the direction of, ‘This is horrible, there’s no way I can stand it, I’m damaged for the rest of my life,’ will likely suffer more (and have less fun) than one who thinks, ‘the majority of people have back pain, and I’m getting more than my share of it, but I know there will be days that are better and days that are worse.’"
A summary of the benefits of exercise:
“Back pain is a major health issue in Western countries and 60%–80% of adults are likely to experience low back pain. This paper explores the impact of back pain on society and the role of physical activity for treatment of non-specific low back pain. A review of the literature was carried out using the databases SPORT-Discuss, Medline and Google Scholar. A general exercise program that combines muscular strength, flexibility and aerobic fitness is beneficial for rehabilitation of non-specific chronic low back pain. Increasing core muscular strength can assist in supporting the lumbar spine. Improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the patient’s functional movement. Aerobic exercise increases the blood flow and nutrients to the soft tissues in the back, improving the healing process and reducing stiffness that can result in back pain.”
Recommendations for a healthy back:
----Always stretch before exercise or other strenuous physical activity.
----Don’t slouch when standing or sitting. The lower back can support a person’s weight most easily when the curvature is reduced. When standing, keep your weight balanced on your feet.
----At home or work, make sure work surfaces are at a comfortable height.
----Sit in a chair with good lumbar support and proper position and height for the task. Keep shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. During prolonged periods of sitting, elevate feet on a low stool or a stack of books.
----Wear comfortable, low-heeled shoes.
----Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
----Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
----Maintain proper nutrition and diet to reduce and prevent excessive weight gain, especially weight around the waistline that taxes lower back muscles. A diet with sufficient daily intake of calcium, phosphorus, and vitamin D helps to promote new bone growth.
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