Mar 25, 2022

Interviewer: You hurt your back. What can you do on your own, and when should you go see a doctor? Dr. Andrew Joyce is a physical medicine and rehabilitation specialist. He's also an expert at helping patients manage neck and back pain.

Dr. Joyce, I was shocked to find out that low back pain is the number two reason Americans see their healthcare provider. Is it for this kind of acute back pain that we're talking about that they're usually seeing their doctor for?

Dr. Joyce: In most cases, yes. I think a lot of people have chronic low back pain as well, but I think most of us tend to see a lot of acute low back pain, and particularly my primary care colleagues see tons of it.

Interviewer: And we're talking in this particular Q&A that we're doing together about acute back pain, which is back pain that you were just doing something and you hurt yourself, right? Is that kind of what we're talking about there?

Dr. Joyce: Yeah. And it doesn't even have to be doing anything in particular, but you wake up, you have back pain, and you don't know where it came from. Or you were lifting something and tweaked something, threw out their back is a common phrase that people will use, all of those count as what we're talking about today.

Interviewer: And technically, when you say "acute back pain," that's back pain that lasts less than four weeks, right, four weeks or less?

Dr. Joyce: Depending on which guidelines you use, some people say four weeks, some people say less than six weeks, but somewhere in that range.

Interviewer: All right. So, but if I hurt my back like one day, I don't know how long it's going to last. So is there a better way to kind of determine what type of back pain I have? I suppose if I was doing something, it's pretty obvious that, oh, well, I tweaked my back doing that. But like this wake up scenario, how could I tell that maybe that isn't a symptom of something bigger? Because a lot of times back pain is a symptom of other things, isn't it, you've got to kind of rule out?

Dr. Joyce: Yeah. Yeah. And so that's when we start looking at kind of these what we call red flags. So it's very common that people will hurt their back, and oftentimes the pain can be very severe and debilitating. Severity doesn't always correspond with something being necessarily worse. There's actually set of red flags that we look for to kind of try to triage and look for people who might be at risk for having other sources of back pain that warrant further investigation.

Interviewer: All right. So before we kind of get to then acute back pain, I think it's really important to hit those kind of red flags to somebody can make an informed decision that they need to see their healthcare provider sooner than later, or trying to take care over themselves. What are those red flags?

Dr. Joyce: Big ones are trauma. Obviously, if you were like in a car accident, that would factor in. If you have new fevers, numbness, tingling, weakness in your legs. If you have a history of cancer, if you're having any bowel or bladder changes, you use any blood thinners, have cancer, have IV drug use, all these things could put potentially be risk factors. And those were reasons that we'd want you to be evaluated more soon.

Interviewer: And if a patient doesn't believe that that's the case, if they truly just believe, oh, I must have slept funny, or I did something, what can a patient do on their own for acute back pain before they need to see a doctor? What are some recommendations you would have?

Dr. Joyce: Yeah. So the first thing we actually recommend is that you avoid bed rest. Fifty years ago, everyone got recommended, "Oh, just stay in bed, let yourself heal." And what we found is that we were actually giving people a lot of bad advice.

What we recommend now is actually that you try to stay as active as you can tolerate. For most people when they're having an acute back pain flare, they're pretty uncomfortable. So even simple things like getting up, showering, cooking a meal, eating can be somewhat uncomfortable, but our recommendations are to actually try to stay active because recovery is faster when you do that.

Interviewer: And is that because you're getting more blood to the area? What's going on there? Do we know?

Dr. Joyce: I'm not sure if we have exact answers on that. Some of it is that we're probably reducing some of the stiffness. When people have a lot of back pain, they don't move their muscles, they get really stiff and that can cause more pain.

I think we're also testing it. Some people with back pain are really afraid that they're going to do damage and so they don't do anything. And so then their muscles start getting weaker. Within a week, you can lose a large percentage of your overall muscle mass just by not moving and staying in bed. And so by keeping your muscle strong and keeping you moving, you help stretch and strengthen those muscles and help your body on the way to recovery.

Interviewer: And this extra moving, you're not going to hurt yourself most of the time. Is that correct?

Dr. Joyce: As long as you don't have one of those red flags, in most cases, you are able to go out and do whatever you need to do, knowing that there may still be some pain due to this flare-up. But it's safe to go out and be active. In fact, it's kind of the treatment of choice at that early stage.

Interviewer: All right. So get active or just be active as much as you can tolerate. What are some other things that a person could do before they go see a doctor?

Dr. Joyce: They can try over-the-counter medications. So nowadays, we have the Salonpas patches or other lidocaine patches that people can use. There are a variety of topical creams. There's Tylenol. There's oral anti-inflammatories that people can take. All of those are over-the-counter and are medications that patients can try out.

Additionally, this somewhat depends on your insurance plan, but sometimes you can get direct access to physical therapy without even needing to see a doctor in certain cases. And so that's often a reasonable place to start.

Interviewer: And then what amount of time doing those types of things should a patient wait until they start to see some relief or start to be concerned that, "Oh, maybe this isn't acute"?

Dr. Joyce: Yeah. So I would give it at least two weeks and see how you're feeling at that point. If at that point you're not getting better, that might be a good time to at least start scheduling an appointment with your doctor. Most patients with back pain will recover within two weeks.

The next set will kind of get better over the course of six weeks. And definitely if it's been over six weeks, it's probably worth seeing a physician to evaluate you.

Interviewer: And then when you come into your physician, you could go to a primary care physician, or could you come to an expert such as yourself at that point? What would you recommend there?

Dr. Joyce: If you have a good, established care with a primary care physician, I think that's a great place to start, and they will often be able to help you. If you have any concerns, or if for some reason you're not able to get in, or you don't have a primary care physician, we're always happy to see people and get people in from the ground up and make sure that they're getting treated appropriately.

Interviewer: All right. And then what types of things would you do at that point for a patient that has gone two to four weeks not necessarily seeing the kind of recovery that they'd like? What are you looking for at that point?

Dr. Joyce: Yeah. So, at that point, we likely would get some imaging, probably starting with an X-ray, just to check to see that the bony structures are intact and there's no new issues. And sometimes there are things on the X-rays that can clue us into other potential sources of pain that we might not otherwise be able to see just from our physical examination.

We'd prefer a full history and a physical examination to really get a better picture of the back pain and understand how it fits in with your other medical conditions and if there's any other rarer conditions that we really need to be looking at.

At that point, then we make a decision, based on everything, on what the next treatment plan should be, whether it be a formal referral to physical therapy, whether it be more advanced imaging in preparation for certain procedures, and considering different injections.

Interviewer: What about surgery at that point, or when does that come into play?

Dr. Joyce: Most patients don't need surgery. And that's one of the great things. The natural history of these, which means how people do if we do nothing and just let people live their lives, is that most people recover with it over time. It just can be very debilitating during that time.

And so, in most cases, surgery isn't recommended. If you do have one of those red flags, I think it's worthwhile to get evaluated, and then we can see whether surgery makes sense. But in most cases, there's nonsurgical options that we will try first and see if we can help get this under control or get your pain better before having you meet with the surgeons.

Interviewer: And then how about you using opioid medications for back pain? Is that ever a good idea?

Dr. Joyce: In most cases, I would say probably not. There are always exceptions to the rule, so I don't want to say never. But in general, opioids aren't really a first-line treatment for back pain. And if you look at the CDC or you look at other organizations, such as the American Academy of Family Medicine, they don't recommend opioids. And part of the reason is that they've been shown to have higher risks, which we all know through the opioid epidemic, but also no significant benefit when compared to other over-the-counter medications. So Tylenol and Advil versus opioids, the studies show that they're roughly equal in terms of controlling the pain and the opioids carry a much greater risk. So, in most cases, we try our best to avoid opioids because we don't want to risk our patient's health.

Interviewer: And when you're talking about over-the-counter painkillers for back pain, do you just follow the directions on the boxes to what your dosage should be, or generally do you recommend to your patients a higher dosage?

Dr. Joyce: It depends on the medication, but, in general, I probably will recommend for Tylenol, you can take up to two Extra Strength Tylenols, and you can do that three times a day as kind of a high-level dose of Tylenol.

And then for the anti-inflammatories, the low doses of the medication tend to be more pain relievers. And at the higher doses, they tend to have a little bit more anti-inflammatory effect. And so sometimes, for a medication like Advil, we can recommend up to three tablets of regular Advil three times a day.

Any more than that, you should probably be seeing a doctor or checking in with them to make sure you're not using too much medication because that can have other side effects.

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