Interviewer: Back pain is one of the most common musculoskeletal complaints of patients, with some studies showing as many as 8 and 10 patients in the United States experiencing back pain at some point in their lifetime. And of those people, 1 in 10 will experience consistent chronic back pain, which can have a real impact on their day-to-day quality of life. And for patients suffering from long-term chronic lower back pain, sometimes physical therapy and exercises are just not enough. So what else can they do for relief?
To explain some of the other effective treatment options available, we're joined by Dr. Graham Wagner. Dr. Wagner is an assistant professor of physical medicine and rehabilitation and an adjunct professor of neurosurgery at University of Utah Health.
Differentiating Acute vs. Chronic Lower Back Pain
Now, Dr. Wagner to kind of begin our discussion, I really wanted to draw the line, what's the difference between say acute back pain, maybe from an injury or a sprain or something like that, versus chronic lower back pain?
Dr. Wagner: If you were going to give it a defined timeline, three months would be an effective cut-off there, and obviously, that's not something that is necessarily set in stone for any person. But that's a fair number to put it at.
The Impact of Chronic Lower Back Pain on Daily Life
Interviewer: What does living with chronic lower back pain look like? Like what kind of impact are these people dealing with for three months or so?
Dr. Wagner: Yeah, it depends on the severity of the back pain people can have. And it's important to say that not all back pain is created equal. In fact, there are a number of different pain generators that can cause back pain. It probably, for that individual, depends on what is the etiology of their back pain. What is the source? What is the primary pain generator?
A big part of it is the severity. On that imperfect 0 to 10 scale, if someone is living at a 2 out of 10, they can probably have a conversation with someone and not notice their back pain. And then when they're maybe driving or doing the dishes, or doing something where their brain is quiet, then the back pain is noticeable. And it is affecting them.
You start getting up to 4 or 5, 6, that more moderate back pain, they might be noticing that throughout all aspects of their day. It might be starting to cause some disability, the inability to do certain things. More moderate back pain can interfere with the ability to do housework, yard work, and tolerate a full day at work depending on what they're doing. Sometimes some back pain is predominant when people are sitting. So if you have a more sedentary job, a desk job, where you're sitting for a significant portion of the day, that can be pretty debilitating. That same person might get up and go to the gym, get on the elliptical machine or something, and not notice any back pain. But from a functional standpoint, that can be very debilitating, because they're at work eight, nine hours a day in a position that doesn't work for them, that exacerbates their pain.
Now, someone with severe back pain, whether acute or chronic, can certainly have a greater effect on their life, inability to ambulate, inability to sleep comfortably and so they're waking up multiple times a night, and that has a whole host of secondary effects.
So it really just depends on that individual's pain, the severity of that pain, and how it's affecting their daily function.
First-Line Treatments for Chronic Lower Back Pain
Interviewer: And for patients that are dealing with this kind of debilitating chronic pain, what is typically the first line of treatment that is effective for them?
Dr. Wagner: Depending on what they've tried in the past, generally, by the time people get to be in pain that's chronic, if it's more than just very low level, mild pain, they've tried medications, and that's oftentimes helpful, depending on the degree to which that pain is affecting them throughout their day. Sometimes it's an effective strategy to take ibuprofen in the morning if the back pain is related to arthritis, like typical wear and tear osteoarthritis like many people experience in their hands or knees or hips, for instance.
But that first half hour of the day is quite difficult. I'll often tell people to try taking a warm shower first thing when they wake up in the morning, or before they even get out of bed, put a heating pad down on their bed and lay there for 10 to 15 minutes, and let the muscles warm up. Depending on a person's size, you can even warm up the joints in the lower back, and you're just moving a little easier when you first get up in the morning and start getting dressed, getting ready for work, and it can just make the day a little easier for people.
Medications
Oftentimes with that type of back pain, that osteoarthritis back pain, that will come back at the end of the day, for a lot of people in the afternoon, or evening. And then medications, like Tylenol, ibuprofen, and other NSAIDs can be helpful at that time too.
Interviewer: So it sounds like we could do some behavioral things. It looks like some medications, some warming up the muscles at the beginning of the day. But what if that doesn't work? What's kind of the next step?
Dr. Wagner: Yeah, then we get into a whole host of other medications for pain. And quite truthfully, for most people, there isn't one perfect medication. Sometimes that comes down to a combination of medications. We have kind of first, second, and third-line therapies. For chronic pain, usually, we do not like to use opioid pain medications. That's sort of when everything else has tried and failed because, with opioid medications, there are a lot of negative downstream effects — endocrine, mood, etc. And as we all know now, these can be very dependency-forming. And I don't mean they necessarily cause addiction, but the body makes certain physiologic adjustments to accommodate chronic opioid therapy. And that is non-negotiable. Even if someone doesn't have an addiction to these medications, there is a list of physiologic changes that can really negatively impact someone in both their function and their psychologic state and their physiologic state.
Interviewer: For a patient who might be, say, hesitant to turn to these types of medications, what are some of the other options that are available to them?
Chiropractic Care
Dr. Wagner: Yeah, so there's a lot of different things that people can try. One of the more common ones is chiropractic care. Some people experience improvement with low back pain by establishing a relationship with a chiropractor who knows them. I think that a reasonable way to determine if it's successful for you is if you can intermittently get care from a chiropractor that offers you a number of weeks of relief at a time or intermittent care when you have flares in back pain, that's probably successful. And if you're happy with that and you consider that successful, excellent.
Acupuncture
Another thing that is quite commonly done, is acupuncture, if you can find a trained acupuncturist that you work well with. And very similarly, if you're able to get intermediate or longer-term pain relief, then that is a strategy that might work for you in the long term in managing your care.
Behavioral Therapies and Psychological Interventions
Another option that actually has some of the strongest data behind it is behavioral therapies and psychological interventions. Some examples might be cognitive behavioral therapy or mindfulness meditation. So the place in the brain, the deeper brain, and I won't get too far in the weeds with this, but the place where the pain is processed, there are other things being processed, fear, anxiety, and oftentimes those start to overlap with chronic pain. And so one thing that we can do is sort of recruit the executive functioning part of our brain, the forebrain, and bring that into kind of tamp down some of these other responses that are occurring in the brain. Those are often quite helpful in adding to the list of our armamentarium and in treating chronic back pain.
Surgery for Chronic Lower Back Pain
Interviewer: So it sounds like when it comes to pain care, it really is individualized. And we've gone through a whole bunch of options that are, say, non-invasive. We have another piece on The Scope, and we'll throw a link in the description, of non-surgical options, like stimulation and injections, etc. to help people with their pain if some of these other modalities aren't working. But at what point, as someone who works with patients who are experiencing say this chronic lower back pain, when do you turn to surgery?
Dr. Wagner: Not being a surgeon, I can give you a sense of when I refer a patient to surgery. As I mentioned before, there are a number of different potential pain generators and a number of different pathologies that can all cause back pain. Some things are much better treated with surgery than others. For instance, if you have a disc herniation, let's just throw it out there, if that person doesn't respond to time, physical therapy, medication management, perhaps some injections, things like epidural injections, and they don't improve, maybe weakness worsens, that person might be an excellent candidate for surgery to move a portion of that disc off of the nerve that it's impinging. That person might be a great surgical candidate.
Another person might be someone who has degenerative changes in the spine, that have happened over many years, narrowing the central canal, where the nerve roots in the lower lumbar or the lumbar region are sort of pinched together as they go through the spinal canal causing oftentimes posterior leg symptoms, worsened when up and walking for maybe a few minutes, improve when people sit down. That's neurogenic claudication that's called, and it's fairly common. Patients like that may be great candidates for surgery, but it very much depends on the individual and what is causing the pain.
Tailoring Treatment Plans for Chronic Lower Back Pain
But for someone that is young, that is just experiencing back pain, I'd have to say I've seen some hesitancy in treating back pain with surgery. And most of the time, we want to optimize non-operative options for that and sort of build a patient's toolbox rather than jumping to surgery, because for back pain, surgery is a little less reliable. And again, you'd have to talk to a surgeon about an individual's case.
Interviewer: For sure, yeah.
Dr. Wagner: But back pain is not as well treated typically as leg symptoms and nerve compression.
Interviewer: I guess as a physician, as a health care provider, as a health care communicator, we all wish that there was kind of this straight answer for complex problems like chronic pain. And for patients who are listening to this, either they or a loved one are reading along or listening along and kind of hearing all these options, it might be a little overwhelming. What is it that you tell a patient who is, first, dealing with chronic pain? What is the kind of hopeful message that they can get as they start trying these different modalities?
Dr. Wagner: I tell them that, hopefully, we'll be able to identify a discrete pain generator that has a fairly reliable and evidence-based treatment that we can do for it. As a physician who treats primarily back pain, I'm looking for what is the pain generator. Back pain is a symptom. It's not a diagnosis. And so the more things that we're able to treat, the more treatments we have for discrete pain generators, the better off we are.
But for a lot of people, when the pain becomes chronic, even treating discrete pain generators is insufficient. It might give temporary relief, but they're still having chronic pain, which is why, and this is not an area that I work in, but we have a phenomenal here at the University of Utah, a phenomenal Chronic Pain Management Center that's able to take more of a holistic look at treating a person's pain. They have embedded physical therapy. They have embedded psychology. They do more medication management than I'm really able to do on top of treating discrete pain generators with interventional therapies too.
And so if we can't find something reasonably quickly that is going to help keep people out of pain for an intermediate or longer term, even though the pain might come back, oftentimes we can find for people something that works for, let's say, six months, a year, two years, and those patients, we can treat with intermittent interventional therapy and it usually works out quite good.
But finding a good, comprehensive pain management program that's really looking at the patient holistically, that's willing to work with the patient to try all these things to find what works for that individual, for a lot of people that's critical.
