The Next Best Thing – Recovering From Chronic Back Pain
By Kit S. Mays, M.D.
Chronic back pain is defined as moderate to severe pain that persists for 6 months or more. It significantly limits normal activities and requires more than simple and occasional analgesics that are available over the counter (aspirin, acetaminophen (Tylenol),ibuprofen (Advil,etc). If even simple analgesics are required daily, or if routine occasional prescription medication (arthritis medication, narcotics, muscle relaxants) are necessary for function or sleep you may have a problem that will benefit from a visit to your physician. There are situations where pain that has not persisted for several months would also cause you to see a physician simply because of its severity. Once the diagnosis has been made as to the cause of our pain, and appropriate treatment instituted, the pain which limited your function may be significantly improved so that you desire no further treatment. In a large number of people, however despite correct initial treatment, the pain may remain and be of such a nature to require further care. For treatment of the remaining pain after the correct diagnosis and treatment the following flowchart may be helpful. By all means consult your doctor. It is a good idea to keep your physician informed of whatever you are undertaking to improve and to ask for a referral to an consultant when you wish to explore other options.
The best thing, of course is not to have severe chronic back pain and to be able to function as you always have. It is ideal if you can heal completely with time, rest, and properly administered acute care. But we are considering The Next Best Thing. The Next best thing is to recover or improve with the following order of interventions. When you go to the next step in the flow chart, you may be able to do the things which will enable you to have physical therapy and /or start an exercise program.
- Physical Therapy
- Medication Management
- Nerve Blocks and Joint Injections
- Surgery ( Spinal Cord Stimulators, Pumps, etc)
- Administration of oral long acting narcotics
In a previous article, I addressed starting an exercise program at home. In summary, the rule of thumb is to start low, go slow and progress relentlessly. You should begin with something you know that you can do safely, and exercise daily (at least 6 days in a row, plan on 7 and allow yourself to take 1 day off if you have exercised 6 days in a row. If you have missed a day, go 6 days before you take a day off.
Your primary physician may also recommend a personal trainer, or send you to a physical therapist for therapy and to start you on an exercise program. Anyone may hurt themselves when they begin to exercise. The safest way to begin to exercise , if you are at an unusual risk or fear of hurting yourself is to begin with a skillful therapist, in a controlled environment, in the water ( aquatic treadmill, therapeutic pool, etc.). Sometimes manipulation or massage may be helpful, and modalities( heat, electrical stimulation) can also be of help when you start exercising. The important thing is to start and then continue. No therapy is likely to help you increase your function in the long term if you do not exercise regularly at home.
If this is not adequate to deal with your situation, consider adding the next step: regular over the counter medication. You should always discuss this with your physician, because many of the over the counter analgesics are prescription drugs in non prescription doses.(i.e. Motrin IB, Advil, Aleve).They may also have serious consequences if you take these medications at recommended doses on a regular basis. (e.g. aspirin may cause bleeding, stomach ulceration or kidney damage; acetaminophen may damage the liver). Just keep your family doctor advised of what you are doing.
Medications which your doctor may prescribe for chronic back pain include anti-inflammatory medication, and intermittent use of cortisone like drugs (steroids), and intermittent use of first line narcotics (codeine, tramadol, etc) progressing to stronger drugs such as propoxyphene and hydrocodone in small doses. Higher doses of stronger narcotics very rarely are helpful as tolerance rapidly develops. The internal system which helps regulate nerve function and healing ( commonly called the endorphins) becomes depressed and recovery of normal function of the nerves becomes compromised. Side effects (constipation, trouble sleeping, depression, nausea, and problems with memory, etc.) are often quite bothersome especially in older patients. In a two year study that was done in California several years ago, 200 patients with chronic benign (non cancer) pain demonstrated very limited pain relief while taking long acting narcotics, and needed dramatic increases in the amount of narcotic required to manage the pain. Antidepressants, and anticonvulsant medications have become a mainstay among physicians treating chronic pain because of the direct effect they have on pain nerves.
Nerve blocks (epidural injections and peripheral nerve blocks) and injections of the joints (shoulder, hips, elbows, and spinal joints etc, ) are used to reduce swelling and inflammation and to allow normal nerve function. Peripheral joints (hips, shoulders, elbows, knees etc) are usually injected one to four times a year and central joints (spinal facets and sacroiliac joints) ,may be injected in short series of treatments. Both nerve blocks and joint injections are helpful in many patients to improve their function. They have relatively few side effects, and are usually about as painful as a penicillin shot. Major nerve blocks are usually performed in an operative suite, especially when radiographic guidance is helpful. A local anesthetic is used during the procedure and most patients decline a sedative before the procedure, although sometimes a preoperative medication is helpful. Nerve blocks and joint injections sometimes eliminate the pain. More often, they give significant relief of pain for prolonged periods of time (weeks to months) by reducing inflammation and welling around the irritable nerves or the damaged joint which allows more normal use of muscles and joints. This is one of the reasons that nerve blocks and joint injections are so helpful at the start of an exercise program.
The next step is spinal surgery for implantation of mechanical devices (intraspinal pumps and spinal cord stimulators). For some individuals with unremitting pain from damaged nerves or cancer, these can be very helpful Usually a temporary treatment can be used to determine whether or not there is a high likely hood of substantial relief with implantation. Both are programmable with a handheld device and require battery changes every few years. Both the stimulation and rate of flow of drugs from the pumps into the spinal fluid can be regulated and adjusted. The pumps must be refilled every few weeks or months depending on the drugs used.
Of course, in all the above treatments, one must pay attention to the treatment of depression, sleep disorder, and other medical problems. Difficult pain often responds to a multidisciplinary approach with physicians of different specialties, physical therapist, psychologist, and specialized pain nurses working together in coordination to provide optimal results. Only the services needed are used, but studies demonstrate that a comprehensive approach succeeds often where single specialty treatment is unable to provide adequate relief, and relief is often quicker with all treating personnel under one roof. Above all, the words of Winston Churchill should be remembered, “never, never, never give up!” What we cannot do today we well may be able to do tomorrow In the history of the world, there has never been a time when more time, efforts and resources have been committed to the search for new ways to control chronic pain. Keep looking for the Next Best Thing.
© Dr. Moacir Schnapp and Dr. Kit Mays