Brunilda Nazario, MD
Most low back pain tends to get better on its own within 4 to 6 weeks, regardless of how it’s treated. But if it doesn’t, it’s time to seek more specialized care.
Decades ago, most people who sought treatment for low back pain went to their primary care provider for medication and an X-ray. If their pain became intolerable, perhaps they ultimately saw an orthopedist for back surgery. But today, back pain is managed by a team of experts, each with his or her own specialty.
“It’s no longer the time when you have one person in the room saying, ‘Here’s how I’m going to treat your back pain,’” says David Fish, MD, a physiatrist at the University of California, Los Angeles, Spine Center and an associate professor in the department of orthopedics at the David Geffen School of Medicine at UCLA. “The standard of care now is a multispecialty team, a group effort. It’s not just medication, not just physical therapy, not just injections -- it’s a combination.”
So who should be on your treatment team for low back pain?
Primary Care Physician
Most people with low back pain usually consult their primary care physician first. Increasingly these days, say experts, your primary care provider is likely to refer you to a multispecialty spine center for the management of significant low back pain. Often, the person in charge of back pain care is a physiatrist.
A physiatrist is a medical doctor with specialized training in the musculoskeletal system, physical medicine and rehabilitation, and pain management.
“We’ll take a history and do a physical exam, and may order imaging, to make a diagnosis,” says Victoria Johnson, MD, a physiatrist at Carle Spine Institute, Urbana, Ill. Two other forms of testing performed by physiatrists to help diagnose back pain are nerve conduction studies and electromyelograms, or EMGs. These tests measure the electrical activity of muscles and nerves.
The next step depends on the specific back problem, says Johnson.
The physiatrist might simply order a combination of anti-inflammatory and muscle relaxant medication. “The goal is to interrupt the pain and open a window to let physical therapy work and allow the spine to heal,” says Fish. “Epidural injections can also improve the diagnosis of where the pain is coming from, and open a therapeutic window.”
“Epidural” refers to a particular space in the spinal cord and not a particular type of medication. Epidurals are familiar as a pain relief measure during labor, but the epidural Fish is referring to doesn't numb your lower body. In the case of low back pain, the physiatrist may inject a small dose of medication and steroid in the epidural space.
“If it’s a pinched nerve in the back or neck with pain going down the arm or leg, I might refer the patient for a specialized injection such as cortisone injections near the spine," says Fish. "That takes the pressure off the nerve and helps relieve the arm and leg pain.”
One of the most important treatments for chronic low back pain is physical therapy. Almost every back pain clinic or spine center will have a physical therapist on staff. Physical therapists are state-licensed health professionals whose primary focus is keeping people mobile and functioning using a variety of exercise and movement therapies.
Your physical therapist will design a program for you that combines core strengthening exercises, aerobic exercises, and “back school,” which builds your awareness of your posture and teaches you what you should -- and shouldn’t -- do to maintain a healthy back.
“They’re our eyes and ears,” says Fish. “They’re spending most of the time with the patient.” Usually, you will see a physical therapist approximately three times a week for three weeks, then ramp down to two times a week for the next three weeks, and once a week for the last three weeks. Nine weeks is the standard course of PT for back pain.
At many back and spine clinics, the physiatrist, anesthesiologist, or pain medicine specialist who administers the specialized pain-relieving spinal injections is also specifically trained as an “injectionist.”
You can become an injectionist via several paths, says Johnson. After completing physical medicine and rehabilitation training, a physiatrist may also undergo a pain management and injection training program that lasts another 1 to 3 years. A doctor may also start out in anesthesia and then do a fellowship in pain management, which offers more experience and training in complex injections.
In addition to epidural injections of cortisone, an injectionist might inject medication into the facet joint [located on each side of the vertebrae] to relieve irritation and inject local anesthetics and steroid medications into specific “trigger points.”
These injections don’t actually heal anything, Fish says. “It’s like putting a Band-Aid over a blister when your shoe doesn’t fit well. That doesn’t change the fact that the shoe (foot interface) doesn’t seem to fit but it blocks the pain so that over time a callous can develop on the foot and the shoe will stretch.”
A chiropractor receives a doctor of chiropractic degree from a 2 to 4 year accredited institution. Chiropractic training focuses on the musculoskeletal system, and chiropractors primarily use spinal manipulation and adjustment to relieve back pain. They also use soft tissue therapies, and frequently also offer massage therapy and exercise training.
“Although we don’t have chiropractors on staff here, I frequently refer patients to outside chiropractors,” says Johnson. “They can be very effective. Both chiropractic and physical therapy can be good first-line treatments for back pain.”
Integrative Care and Other Practitioners
Depending on your personal situation, your physiatrist or other back pain specialist may suggest that you see other types of caregivers, including:
At some point, back pain may become so severe and debilitating that your treatment team may recommend surgery.
The recommendation may depend on the severity of your symptoms as well as your specific diagnosis, says Johnson. “If you have generalized degenerative disc disease and lots of arthritis, you probably won’t do well with surgery. Surgery for back pain doesn’t work well with multi-level disease."
However, Johnson says, a reasonably young patient with a single herniated disc, or someone in his or her 50s to 70s with single-level spinal stenosis (narrowing of the spinal canal), can do very well with surgery.
If surgery is right for you, what kind of surgeon will you see? You may be treated by an orthopedic surgeon, who specializes in the musculoskeletal system, or a neurosurgeon, who specializes in the brain and central nervous system, including the spine.
In most cases, either a neurosurgeon or an orthopedic surgeon can perform whatever spinal surgery you might need, says Johnson. “Ten years ago, that might not have been the case. Neurosurgeons weren’t always trained to do fusion and the bone procedures that orthopedists do, but now they get the same training that orthopedic spine surgeons receive.”
In addition to procedures like spinal fusion and lumbar disc replacement, surgeons can also implant a device called a spinal stimulator, which uses electrical impulses to help control chronic pain.
SOURCES:David Fish, MD, physiatrist, University of California, Los Angeles, Spine Center and associate professor, department of orthopedics, David Geffen School of Medicine, UCLA.Victoria Johnson, MD, physiatrist, Carle Spine Institute, Urbana, Ill.Cherkin, D. Archives of Internal Medicine, 2009; vol 169: pp 858-866.Hoffman, B. Health Psychology, January 2007; vol 26: pp 1-9.
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