“Our best understanding of low back pain is that it is a complex, biopsychosocial condition — meaning that biological aspects like structural or anatomical causes play some role but psychological and social factors also play a big role,” Roger Chou, a back pain expert and professor at Oregon Health and Science University, summarized.

For example, when you compare people with the same MRI results showing the same back injury — bulging discs, say, or facet joint arthritis — some may experience terrible chronic pain while others report no pain at all. And people who are under stress, or prone to depression, catastrophizing, and anxiety tend to suffer more, as do those who have histories of trauma in their early lives or poor job satisfaction.

The awareness about the role psychological factors play in how people experience pain has grown more widespread with the general shift away from the dualist view of the mind and body toward the more integrated biopsychosocial model. Chronic nonspecific low back pain “should not been considered as a homogenous condition meaning all cases are identical,” researchers in one review of the research on exercise cautioned.

A new understanding of pain called “central sensitization” is also gaining traction. The basic idea is that in some people who have ongoing pain, there are changes that occur between the body and brain that heighten pain sensitivity — to the point where even things that normally don’t hurt are perceived as painful. That means some people with chronic low back pain may actually be suffering from malfunctioning pain signals.

Enter alternative therapies for chronic back pain

Despite the clear risks, doctors have continued to prescribe painkillers, and perform surgeries and injections, sometimes to patients who won’t take no for answer or who can’t afford to try alternatives (which usually aren’t covered by insurance plans).

Slowly, though, the tide is shifting.

Medical societies and public health agencies are now advising doctors to try less invasive options and even alternative therapies such as acupuncture before considering opioids or surgery.

Most recently, in February 2017, the American College of Physicians advised doctors and patients try “non-drug therapies” such as exercise, acupuncture, tai chi, yoga, and even chiropractics, and avoid prescription drugs or surgical options wherever possible. (If the non-drug therapies fail, they recommended nonsteroidal anti-inflammatory drugs as a first-line therapy, or tramadol or duloxetine only as a second-line therapy.) In March 2016, the Centers for Disease Control and Prevention also came out with new guidelines urging health care providers to turn to non-drug options and non-opioid painkillers before considering opioids.

At the same time, research has mounted suggesting active therapies (exercise programs, yoga, tai chi) can really help people work through back pain, and alternative approaches (massage, spinal manipulation) can be effective, too — with the caveat that they’re often no panacea and the effects tend to be short-lived and moderate.

But most of the alternatives also carry little or no harm (except to patients’ pocketbooks) — which makes them all the more appealing amid the historic drug crisis.

“We have a slew of modalities and procedures that the American College of Physicians cannot endorse — such as opioids, fusion surgery, such as injections,” Ramin said, because there’s now so much evidence of ineffectiveness or harm. “So all those things are off the table, and now they are looking for things they can endorse that will not cause harm.”

Moving is probably the most important thing you can do for back pain

When back pain strikes, your first instinct may be to avoid physical activity and retreat to the couch until the pain subsides.

But doctors now think that in most cases, this is probably the worst thing you can do. Studies comparing exercise to no exercise for chronic low back pain are consistently clear: Physical activity can help relieve pain, while being inactive can delay a person’s recovery.

Exercise is helpful for a number of reasons: It can increase muscle strength, which can help support the spine; It can improve flexibility and range of motion in the back, which can help people’s functional movement and get them back to their normal living; it can boost blood flow to the soft tissues in the back, which promotes healing and reduces stiffness. These are just a few reasons why researchers who study back pain suggest opting for exercise before some of the passive therapies like acupuncture or massage (we’ll describe those later).

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