Chronic Back Pain: What can I do now?

Unfortunately, no one has a magic wand to eliminate your pain. We will not deceive you into believing there is a simple explanation, procedure, or medication that will eliminate your pain. If there were a simple, quick fix to your pain, all of the thoughtful doctors you have seen would clearly have embraced that approach. If it seems you are getting mixed messages, then a simple solution to your pain may not be available. Your pain is a complicated condition in which some peripheral pain signals from weak, stiff or improperly functioning muscles involuntarily become amplified within the spinal cord. Blocking and even reading these pain signals is beyond the technology that we currently have in medicine. You may need to redefine successful treatment of your back pain, and focus on a more practical solution. Thousands of people have been able to successfully manage their pain and participate in normal age-appropriate work and recreational activities. If you are sufficiently willing and motivated, we can teach you how to perform active physical and mental exercises that have been helpful to the many of our patients with chronic back pain we have seen over the past 25 years.

What can I do to manage back pain?
Our goal is to give all patients an adequate explanation for their pain so that they understand what medical care can and cannot do, and they can start to focus on rehabilitation. A key focus of this guide and many of the international medical treatment guidelines22 for chronic back pain is helping people self-manage their condition: reduce pain and its impact on a person’s day to day life even if the pain cannot be cured completely. We encourage people to stay physically active and continue with normal activities as far as possible. We provide information about the expected course of their pain and effective self-care options. Treatment should take into account patient’s needs and preferences, informed decisions, and involve good patient-physician communication. Studies23 have shown that patients who do not receive an adequate explanation for their pain frequently want more diagnostic tests and were less satisfied with their visit or to want the same doctor again.
What do national guidelines recommend for reasonable medical treatments for chronic back pain?

For people who do not improve with self-care options, several national24 and international25 guidelines recommend up to 8-10 sessions of individual or group exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation over a period of 12 weeks.

For people who have failed the above treatments or have high disability or psychological distress, physicians are recommended to consider referral for a combined physical and psychological treatment that include approximately 100 hours over 8 weeks. The UI Spine Rehabilitation Program includes approximately 80 hours of professional contact involving the physician, psychologist, and physical therapists over two weeks.

What are national guidelines recommending for medications to use for chronic back pain?
The American Pain Society and the American College of Physicians recommend acetaminophen or nonsteroidal anti-inflammatory medications. Second line treatments for chronic back pain include tricyclic antidepressants.
Will you prescribe opiate medications for me?

Opiate pain medications for the control of chronic back pain are controversial. Over 9 million adults in US (3% of the adult population) receive long term opioid therapy and another 5 million abuse them for chronic non-cancer pain yet this form of treatment is not supported by research. The American Pain Society and the American Academy of Pain Medicine are concerned about harms of opiate medications including drug abuse, addiction, and diversion. Of the patients taking opioid medications, only about a quarter of the patients had their pain decrease by 1/3. Only 1 in 6 people actually improved their ability to function or return to work or do more activities. Higher dosages were not associated with any increase in clinical improvement. Serious opioid overdoses occur among stably insured patients on long-term opioid therapy for chronic pain. For all the above reasons, the UI Spine Center does not recommend the use of opiate medications. There are many reasons we feel this way: opiates do not decrease chronic pain very well, what effectiveness they have wears off, and there are serious long term harmful effects including addiction, osteoporosis, immune suppression, sexual dysfunction and increased pain.

Our most successful patients have been able to wean themselves off their opiate medications over several weeks time. If you are currently taking an opiate medication contact your prescribing physician for instructions on how to start this process. Many of our patients say that they feel far better when they are not taking opiates. Fear about experiencing increased pain can lead to increased use of even more powerful pain medications and long term disruption of hormonal function. You are the best person to decide when to stop this cycle.

We hope you can see why would we do not choose to use opiate medications when we have the Spine Rehabilitation Program which has a long track record of success and virtually no risk of harmful side effects.

Do these pain rehabilitation programs really work?

Researchers have done extensive reviews which “clearly revealed that chronic pain programs offer the most successful and cost-effective treatment for persons with chronic pain even including spine fusion surgery.” This has also been confirmed by the American Pain Society and the American College of Physicians and has been an integral part of their Clinical Practice Guidelines. There is also strong evidence that a graded activity program using a behavioral approach is more effective than usual care in getting patients back to work.

Many patients with back pain do not qualify for Social Security Disability. A person who understands the causes of their back pain and is sufficiently motivated to improve their ability to cope with their pain should definitely be encouraged to participate in age-appropriate work, physical, and recreational activities without limitation.

So if a patient continues to have pain even after a combined physical and psychology program, would surgery be indicated?

“Intense pain is not necessarily an indication for surgery,” says Dr. Richard Deyo, Professor at Oregon Health Sciences University. Surgery for radiculopathy or ankle or toe weakness or pain can be effective. Surgery for axial back pain generally is not successful in eliminating back pain. People typically overestimate the potential benefits of fusion surgery for degenerative disc disease. Less than half of patients surveyed had good outcomes (having only rare pain, slight limitation of function, and only occasional use of pain medications). In another study of patients who underwent spinal fusion, 64% who had fusion were still off work more than 1 year after fusion surgery, Only 6% had gone back to work, 20% had complications, 27% reoperation rate, and 90% were still taking narcotics.

Spine fusion operations are expensive. Twice as many of these surgeries are done by American surgeons as done in European countries, and up to five times more than done in England. New England Health Care Institute estimates US could save $1 billion a year by eliminating unnecessary back surgeries. We at the UI Spine Center are concerned about the excessive use of opioid medication, unnecessary advanced imaging and testing (MRIs and EMGs), overuse of pain injections for low back pain, and the potential for overuse of lumbar fusion surgery.

We firmly believe that “The patient knows best.” When people are fully informed of the risks, benefits, and likelihood of success and share in the responsibility of making their treatment decisions, people are more likely to choose conservative (non-surgical) treatment options. It is also comforting to know that research from the American Pain Society indicates behavioral treatment and fusion surgery can share the same functional results. Spine fusion surgery is NOT the only way to get better.

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Department of Orthopedics and Rehabilitation
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, IA 52242
319-356-8400