Back Pain: What Works

Simple treatments may help as much as high-tech gadgets or surgery.

James Weinstein, an expert in back pain at Dartmouth-Hitchcock Medical Center, was bending down two years ago when his back went out. The pain was so bad he could hardly breathe. For ten minutes "my hands were on my knees and I couldn't stand," the renowned orthopedic surgeon says. He hoped none of his patients would happen by and see him. It took him ten minutes to struggle out to his car.

As he lay on his back at home, his wife politely reminded him of the advice he gives his patients: Take some aspirin, get out of bed and get back to a normal routine as soon as it's tolerable. The next day he forced himself to take a jog. The first steps were excruciating, but by the end he felt a little better. He recovered a week later.

Back pain hits tens of millions of Americans every year. The cost of treating it was $86 billion in 2005, up 65% (in real terms) from 1997, a recent University of Washington study estimated. Where did the money go? Brand-name narcotics and all sorts of new gadgets. But the same study found that patients aren't feeling any better than they did a decade ago. "A lot of the things we are doing aren't offering much benefit," says Richard Deyo, of Oregon Health & Science University, one of the study's coauthors. The good news is that according to recent studies, several low-tech approaches do appear to help. Here are some pointers:

Time is on your side

Most acute back pain episodes resolve on their own. A 1995 study of 1,633 North Carolina residents who had reported back pain to their practitioners found that they recovered full functioning in 16 days, on average; only 31% had any residual pain six months later. "The natural history is very favorable. Time is on your side," Deyo says. Even if you have chronic symptoms, odds are they won't lead to serious medical consequences; 85% of back pain cannot be linked to any specific anatomical problem. Chronic pain may be caused partly by sensitized nerves that keep firing well after the original source of the pain is gone, researchers believe. "Hurt doesn't mean harm," says Weinstein. "Most people don't know this and get scared." Exceptions include if you have alarming symptoms such as progressively worsening pain; pain that wakes you up; or pain accompanied by fever, unexplained weight loss or bowel or bladder problems.

Stay active

For decades doctors used to prescribe bed rest for back pain. Now they realize this is exactly the wrong advice. For acute back episodes, the key is to return to normal activity as soon as you can. A 1995 Finnish study compared back patients who were prescribed two days of bed rest with those who were advised to resume normal activities when they could. The patients assigned bed rest recovered more slowly and took more sick days. One reason may be that the spinal disks between the vertebrae don't have their own blood supply; they need motion to move nutrients in and waste out, Weinstein says.

For those with chronic back pain, a formal exercise program can help, according to a 2005 Annals of Internal Medicine analysis of 43 previous studies. The exercise can help strengthen muscles, improve general conditioning and have a positive psychological impact, as the sufferer realizes the pain isn't as limiting as it seemed. It may also raise endorphin levels. Go to www.nlm.nih.gov/medlineplus/tutorials/backexercises/htm/ index.htm.

Low-tech remedies work

As director of clinical guidelines for the American Pain Society, Roger Chou, an internist and colleague of Deyo's at the Oregon school, recently spent three years reviewing the scientific literature to see what works best for back pain. His conclusion: Stick with a low-tech, noninvasive treatment unless you have a good reason to do otherwise. Besides exercise, he found three low-tech regimens with strong statistical evidence for their use: spinal manipulation from a chiropractor or osteopath (why this works isn't clear); interdisciplinary rehabilitation programs that combine supervised exercise and counseling; and cognitive-behavioral therapy, which helps you develop coping skills and prevents panic about the pain. In patient trials all these approaches reduced back pain by moderate amounts, Chou says. The drugs with the best data behind them for back pain include anti-inflammatories like ibuprofen and naproxen and muscle relaxants like Flexeril to treat acute pain. For more detail, see the Oct. 2, 2007 Annals of Internal Medicine. Go to www.annals.org/cgi/content/full/147/7/478.

Chou has also reviewed the evidence for numerous high-tech procedures, including everything from spinal injections to needles that burn spinal disks. Few have convincing studies behind them, he says: "It is really kind of shocking." An exception is surgery for specific problems such as a herniated disk pressing on a nerve (see box).

An MRI may not help

Up to 90% of people get worn-down spinal disks and other spine imperfections as they age that can be spotted with magnetic resonance imaging. But doctors often can't determine whether those problems are the cause of back pain. In one Journal of the American Medical Association study, back patients who got MRIs didn't have any less pain a year later, but they were more likely to have had surgery. "Most imaging tests don't give us useful information, and may lead to unnecessary operations," says Chou. An MRI makes best sense for those considering surgery or if serious conditions like cancer or neurological problems are suspected.