hi I'm dr. Mike Evans and today we're
talking about low back pain a problem
that people often take care of
themselves but even then it's still one
of the top two reasons people visit
doctors and responsible for up to 40% of
all missed work days okay let me begin
by giving you a bit of a mixed message
for most of us back pain is actually not
a quote disease it's more part of the
normal experience since we've walked on
two legs
spinal structures such as bones
ligaments discs joints and nerves
interacted marvelous ways to support us
to do the million things we do with our
backs but occasionally this backfires
and gives us what we call mechanical
back pain the severity of the pain which
which can be extremely but always
reflect the seriousness of the
underlying problem and the vast majority
gets better by itself without medical
intervention on the other hand we know
that while it does get better thirty
percent of you have a recurrence in six
months and forty percent within a year
if this sounds familiar it may be
helpful to stop seeing your recurrent
back pain is discrete event and and more
is a chronic vulnerability that you need
to create what I call a back resilience
plan maybe learn some lessons from
people who manage their chronic disease
as well they build a support team and
reach out early when there's a problem
they make small changes and they focus
on basics like managing stress getting
quality sleep and keeping up so let's
start with the pain itself let's keep it
simple and talk about two patterns first
is what we call back dominant pain most
commonly this pain radiates down the
back to our butt and or around the hips
some patients just have pain in the back
and others can sometimes feel the pain
all the way down the leg but it's a back
pain that is dominant most of these
patients get relief or aggravation of
pain with particular movements or
positions for example when they arch
backwards or bend forwards typically
this kind of back pain comes and goes or
it comes in spasms as you move in fact
back dominant pain is a good pain
because there's no damage to the nerves
or spinal cord and and no surgery is
needed the second pattern is leg
dominant pain and there are two common
presentations the first typically comes
from a disc problem that puts pressure
on the nerves in your back and it
travels down the legs this is often
referred to as sciatica when this
nervous compressed
or irritated we get pain down the leg
anywhere from below the buttock to the
foot there may be pain in the back as
well but this time the leg pain is
dominant it's a constant pain but tends
to feel better when we lie down
sciatica often gets better by itself but
we may need to give you special advice
there or medications and sometimes
imaging especially if there are thoughts
of surgery so it's a good idea to talk
to your care team if you have sciatica
the second presentation is a leg pain
that predictably comes only when you
stand or walk or run and is relieved
when you bend forward and especially
when you sit the pain can be anywhere in
the leg and patients describe a gradual
worsening or or heaviness in the legs as
they walk which causes them to stop the
medical term for this leg pain is
neurogenic claudication and it typically
happens to people over 60 and is caused
by significant narrowing or or what we
call stenosis of the spinal tunnel
containing the nerves when this gets
severe makes it hard for your nerves to
keep up with your activity
now pain predominantly in the back
especially if it is intermittent or
short lasting is almost always benign
but it's good to quickly review what we
call red flags science that you may need
more investigation the first red flag is
a sudden change in your normal bowel or
bladder control or numbness around the
groin and rectal area which makes us
think something might be pressing on the
spinal nerves there the second red flag
wonders whether infection is the source
of your back pain so for example if you
have a sustained fever if you're an IV
drug user if you have a weakened immune
system or at high risk for urinary or
other infections the third red flag is
about your risk for fracture in your
back so if your pain started with a big
fall or a car accident or perhaps your
bones are brittle because of
osteoporosis the fourth red flag is
wondering whether cancer might be
involved so if you have a history of
cancer particularly in the prostate
breast or lung and your pain is constant
lasting weeks even when lying down or at
night or you have other insidious
symptoms such as unexplained weight loss
you need to follow this up and finally
there's back pain that comes from
diseases that cause lots of information
such as ankylosing spondylitis now this
is rare but when we look at people with
chronic back pain it can be seen in as
many as one in
20 it tends to start when people are
younger say ages 15 to 35 they have
night pain and lots of morning stiffness
lasting over an hour but this gets
better with movement after red flags the
next question we often get in clinic is
should I have an x-ray or a CT scan or
MRI so if you have a red flag or
considering surgery for constant leg
pain imaging may be an excellent idea
but less than five and a hundred
patients will actually have a red flag
so does having an x-ray help for the
other 95 the answer is no professor
richard deo and his group calculated
that only one and 2500 back x-rays show
an important finding okay you say so not
too helpful but what's the harm well
there's a radiation there's wasted time
and money but it's more than that
one famous study mr IED 98 people with
healthy backs and no back pain and found
disc problems and two-thirds of them the
problem with this is that it turns out
your outlook or your attitude is
actually very important to outcomes and
low back pain what we don't want is
people saying to themselves oh I have
back disease so I better stop exercising
or every time they feel a twinge they
feel they have a quote illness this
brings us to the next type of flags what
we call yellow flags these four flags
predict an increase risks is somebody's
acute low back pain will become chronic
number one is the belief that back pain
is harmful or potentially severely
disabling secondly is fear and avoidance
of activity or movement because of back
pain when I think of these two risk
factors
I actually think of a trial done with
baggage handlers and maintenance workers
at an airport we're in bad shape from
back pain and have been off work for a
month dr. Bart stall and his colleagues
in Maastricht a beautiful town in the
Netherlands divided these workers with
severe low back pain into two groups the
first group received usual care the
second group received the same but we're
also slowly exposed to more and more
activity and exercise and we're
conditioned to understand that they can
function normally despite the presence
of some back pain with their activity in
other words the investigators helped
them overcome yellow flag number one the
belief that all back pain is harmful and
that opened the door to overcome yellow
flag number to reducing avoidance of
activity
it was mind over matter if the worker
didn't mind some pain the back pain
actually didn't matter the third yellow
flag was a tendency towards low mood and
isolation which is so true of all
chronic diseases and the fourth yellow
flag was a strong expectation that
passive rather than active treatments
will help believing you just need to sit
there and have therapists work on you
rather than owning the fact that it's
not just a therapist that need to do the
work you do too so now you know what to
watch for let's end with what works for
back pain let's start with movement
until the late 1990s advice to rest was
a common treatment approach for low back
pain the exact nature of the rest varied
but often a man stayin in bed full time
what we know now is that this actually
makes people worse sometimes people with
back pain do have to rest so for example
with more severe sciatica but people who
don't move at all do worse motion is
lotion and over-the-counter medications
can really help and I think why the key
ways these work is to reduce pain so
that you can keep moving other things
have demonstrated effectiveness for pain
relief include spinal manipulation
typically by a chiropractor or an
osteopath massage and even acupuncture
these therapies combined with exercise
can be considered active therapies and
are often done by your local
physiotherapist some exercise strategies
may be effective once your pain is
reduced like Pilates or yoga to improve
your core or trunk strength but the
benefits are hard to prove in research
trials treatments like spinal
manipulation or acupuncture should not
be done indefinitely most of the trials
maxed out at eight to ten sessions and
often less if they don't work for you
initially more treatments will unlikely
benefit to other approaches that have
been proven to work especially for more
chronic back pain our cognitive
behavioral therapy changing the way you
think and therefore behavior on low back
pain and being taken care of by what we
call a multidisciplinary team a team
with different skill sets we see this
often in medicine complex problems seem
to rarely find a solution in one place
okay let's step back and summarize first
you need to know that the prognosis for
acute low back pain is excellent only
about one-third of patients with
back pain seek medical care so most
improve on their own over time up to 90%
of patients we do see with acute low
back pain recover the first episode may
be brief or last several weeks but it
does go away unless they're red flags
these people do fine by acknowledging
the pain but not focusing on it by
keeping moving and perhaps having some
active therapy but there's no need for
x-rays or other imaging generally less
is more with this type of back pain
although there is less high-quality data
to support this many patients often
respond to small changes such as
modifying their workstations taking
breaks from sitting or improving their
posture for those with chronic or
recurrent pain the outlook is still good
primary care samples suggest that 1/3 of
patients are substantially improved
after just a few weeks and 2/3 after a
few months but with recurrent or chronic
back pain we both need to work a little
harder to get you better as I mentioned
earlier seeing this vulnerability and
developing a resilience plan for your
back that might include yoga or pilates
or specific exercises have fit with your
back pain pattern walking reconsidering
your attitudes and having some people
you can turn to early for active therapy
can all help so in the end back pain is
actually not that much different than a
lot of things in life your mindset and
daily habits are critical and so is
self-knowledge trying to feel the
treatments we've discussed knowing what
works for you knowing red flags and when
you need to seek care and finally
understand that movement is medicine
thanks and take care
you