Follow the 'rule of 3's' on back pain
By: Judy Foreman
09/09/1996
Annie Baehr, who works at the Berklee College of
Music, figures she has struggled with back pain for nearly 40 of her
55 years.
For a while, the Winchester woman says, she
trudged to orthopedic specialists, but "nobody gave me any relief."
Last year, when the back pain evolved into daily headaches, she
turned to prescription painkillers, but they didn't help either. The
pills "covered up the pain," she says, but made things worse when
she stopped.
Cherie Hoffman, 35, a Wellesley mother and
publisher of a travel guide for students, has trod a similar path,
searching fruitlessly - until recently - for any method or magician
who might ease her pain.
"I was living on Advil," she says, from the pain
of lifting her kids in and out of car seats. "My back was killing
me."
Back pain, especially in the lower back, which
bears the brunt of the human penchant for walking upright, is
endemic - and probably has been since our species got off all fours.
In fact, it's so common that some specialists say
"it's normal if you have it and abnormal if you don't," jokes Dr.
Edward Hanley, chairman of orthopedic surgery at Carolinas Medical
Center in Charlotte, N.C.
Over a lifetime, 80 percent of us will have at
least one episode of incapacitating back pain, the data show, making
bad backs second only to colds as a reason to see a doctor, and the
leading reason for missed days of work among under 45. The good news
is that even when back pain is acute, the best remedy is almost
always common sense and tincture of time.
Usually, relief comes in a few days if you pop a
few over-the-counter anti-inflammatory drugs (judiciously, so you
don't get an upset stomach or ulcer), apply ice packs or heating
pads (it doesn't seem to matter which, though heat may feel better
on muscle aches and cold on acute injuries) and lie down for a few
hours or, at most, a few days.
Then get up and get on with life, including
regular walking, biking or swimming with a few sit-ups or
back-strengthening exercises thrown in for good measure. Staying in
bed more than two days, research shows, can do more harm than good -
it weakens bones and muscles and creates a "sickness" mentality.
In fact, for most bad backs, you don't even need
to call a doctor unless pain is severe or doesn't begin to go away
within a few days. Just follow what Dr. Howard Martin, an orthopedic
surgeon at New England Baptist Hospital and at SportsMedicine
Brookline, a clinic for athletes, calls "the rule of threes."
"If your pain starts to get better by three days
and is all gone by three weeks, it's perfectly safe to ignore it,"
he says. Even pain in the buttocks or back of the thigh doesn't need
medical attention, he adds, unless it shoots below the knee, a sign
of possible nerve irritation from more serious injury.
Your bad back does need an immediate professional
evaluation, however, if you can't control your bowel or bladder or
if you feel numbness in a leg, the groin or rectal area - all signs
of possible damage to the spinal nerves in your back.
In the old days, back specialists assumed that
most lower back troubles stemmed from problems with the squishy
discs that act as shock absorbers between the vertebrae.
Today, these slipped, herniated or ruptured discs
- all terms for the same problem, in which the gristle-like disc
gets pushed out of position and pinches a nerve - are believed to be
a serious problem for only about 2 percent of the population.
And even for disc patients, specialists say,
surgery is no longer as common as it once was because 75 percent of
disc problems get better on their own over time.
In fact, surgery helps in only about one in 100
cases, according to a 1994 report from a panel of low back pain
specialists convened by the government's Agency for Health Care
Policy and Research. It is generally reserved for patients with
sciatica - pain that shoots down the leg past the knee.
Most back pain, in other words, is caused not by
structural damage to the spine, nor by even rarer tumors or
infections, but by run-of-the-mill soft tissue problems like muscle
strains and ligament sprains.
But run-of-the-mill pain is definitely no joke,
especially when it's your back. So what really works and what
doesn't?
That depends on whom you talk to, and there is an
embarrassment of specialists in the booming $ 50 billion-a-year back
pain industry, all eager for your health care dollars.
You might, for instance, take your bad back to an
orthopedic surgeon, an M.D. who, historically, may have been
inclined to steer you toward surgery but today may well be open to
other options. Or you can try a physiatrist (also called a medical
orthopedist), an M.D. who is not a surgeon but has orthopedic
training.
Or you can look for an osteopathic physician - a
challenge in Boston, but easier elsewhere. Osteopaths (D.O.s) are
not M.D.s, but they get almost identical training and the same
license and have extra training in spinal manipulation.
If you'd rather see a non-physician, you can try a
chiropractor, who has more than four years of post-college training
and specializes in spinal adjustments; a physical therapist, who can
suggest exercises for weak muscles and gentle mobilization of spinal
joints; or a massage therapist, who can massage away some aches and
pains, at least temporarily.
With so many pros to choose from, does it matter
whom you pick? For truly serious problems, yes, which means you
should probably see a physician of some type, including an
internist, at some point. But for less serious troubles, it probably
doesn't matter much, since you're destined to get better anyway.
There is consensus, according to the 1994
government panel, that spinal manipulation by a chiropractor or
osteopath does help, though if it hasn't worked for an acute episode
of back pain after four weeks, you should stop and reevaluate.
You can also use friends' testimonials to guide
you through the maze, but this can be as confusing as listening to
the pros.
Cherie Hoffman, for instance, raves about the
hands-on help she's gotten from her osteopath in Rhode Island, which
makes sense to Dr. Charles Radbill, an osteopath in Wellesley Hills.
Radbill believes that the root of much back pain
is joint dysfunction - particularly in the sacroiliac joint in the
pelvis. Gentle osteopathic manipulation, he says, including of
fascial tissue that wraps around muscles, can help considerably.
Osteopathy "has been a miracle cure for me," says
Hoffman, who stayed away from chiropractors because she disliked
"the thought of having somebody crack my back into submission."
But her sister-in-law, Penney Hoffman, 37, a
Marblehead human resources manager, wouldn't take her aching back to
anyone but a chiropractor. She's so enthusiastic, she calls her
chiropractor her "primary doctor" and even has him treat her kids,
though her insurance doesn't cover it and the family pays $ 1,500 a
year.
That kind of passion is familiar to Barry
Freedman, a Quincy chiropractor, who is convinced the basic problem
in many bad backs is subluxation, or misalignment of the spine,
which puts pressure on nerves and triggers muscle spasms.
Muscle relaxants or physical therapy are "not
going to get rid of subluxation," Freedman argues, but chiropractic
can.
And what of other things like traction, TENS
(transcutaneous electrical nerve stimulation), massage, biofeedback,
acupuncture, injections, corsets and ultrasound?
If you believe the government panel, none of these
speeds recovery from acute back pain or wards off recurrences,
though they may offer short-term relief. But practitioners - and
patients - tell a different story.
Massage therapist Linda Whitcomb of Concord Avenue
Physical Therapy Associates in Cambridge, for instance, says massage
can loosen tight muscles "so that when you lift something awkwardly,
you won't put as much strain on the muscle."
Her partner, physical therapist Nicholas R.
Giurleo adds that physical therapists can also teach you to prevent
back problems by sitting right so as not to overstretch ligaments,
and lifting things correctly, with a slight arch in your back.
They can also prescribe individualized abdominal
and back exercises to help keep muscles strong in the "body core,"
says Michael Wood, a research associate at Tufts University.
If you already have a bad back, though, take care
before embarking on any exercise program, warns Daniel Dyrek, a
physical therapist at the Institute for Health Professions at
Massachusetts General Hospital. Generic exercises that are not
tailored to your specific problem may do more harm than good.
But the most important message, he says, is that
if you're not getting better with whatever specialist you're seeing,
try another one, either in the same discipline or another.
Annie Baehr seconds that notion.
Thanks to osteopathy, she says, "I am getting
better." But like many others who struggle with bad backs, she has
found that true healing is "a long, long process."
To learn more
For more information on low back problems, call
the Agency for Health Care Policy and Research, 1-800-358-9295.
You can also get information from this agency on
the Internet by clicking on:
http://www.ahcpr.gov/ and then clicking on "guidelines" and
following the directions from there.
1. Back pain is almost normal, jokes Dr. Edward
Hanley.
2. Barry Freedman thinks spinal misalignment is a
factor in back pain.
