Decision making lower back pain handout

INFORMATION FOR PATIENTS REGARDING LOW BACK PAIN AND INFORMED MEDICAL DECISION MAKING SO YOU HAVE LOW BACK PAIN… Low Back Pain (LBP) can be excruciating. It might be scary. You may feel as if you are never going to get better, back to normal and be able to function. It may seem that getting X-rays right away to find the exact cause and alleviate the pain might be a good idea. You may feel as if you should see a doctor to get prescription pain medication or go to a physical therapist or chiropractor as soon as you feel a twinge. But that’s not necessarily so.

Later we will discuss some warning signs that may make it a good idea to see a healthcare practitioner sooner rather than later.

Most people will get over low back pain in days to a few weeks with simple self-management steps: • • • • •

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Stay Active: Don’t rest in bed for more than a day. This can cause stiffness, depression and weakness.

Instead, avoid activities that exacerbate the pain but keep moving comfortably if possible.

Apply heat: a heating pad, electric blanket or warm bath/shower relaxes muscles.

Consider over the counter medications such as Acetaminophen (Tylenol) , Ibuprofen and or Naproxen (Aleve).

Sleep comfortably: Lying on your side with a pillow between your knees or on your back with a few pillows beneath your knees can help.

Talk with your doctor: If symptoms don’t improve after a few days, consider seeing a doctor to make sure that the problem doesn’t stem from a serious underlying health problem. If the pain is severe, ask about prescription pain relievers.

Consider alternatives: If you don’t feel better after about 4 weeks, talk with your doctor about other options, such as physical therapy, chiropractic care, yoga, massage, acupuncture, cognitive-behavior therapy and or progressive muscle relaxation. More invasive choices such as surgery, in the absence of neurological problems, should be considered only if those other treatments don’t help.

If you see a doctor or other health practitioner for low back pain, he or she will do a focused history and physical exam and try to determine whether you fit into one of three groups: non-specific low back pain, back pain in which the spinal cord or nerve roots may be pinched, leading to neurologic deficits, or low back pain due to another underlying cause.

Non-specific LBP is the cause about 85-90% of the time. It is due to strain on bones, muscles, ligaments and tendons. It can hurt a lot, but again, usually goes away with conservative treatment after just a few days to a month.

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SHOULD YOU HAVE SOME KIND OF IMAGING STUDY OR XRAY RIGHT AWAY? Studies have shown that X-rays, including plain films, CT scans and MRIs are beneficial only if the pain worsens or persists despite initial care or if a patient has signs or symptoms of other serious underlying illness. Although most patients do not need them, many patients with non-specific LBP will get radiology tests of one type or another. We will discuss the pros and cons of imaging. In addition, a guideline that many physicians use to evaluate and treat LBP is attached here.

PROS: Here’s why getting an IMAGING TEST for BACK PAIN might be a good idea: 1. If you have serious nerve damage, such as bowel or bladder problems or weakness or spasticity in your legs, especially if they are getting worse along with the pain, a study such as an MRI is a good idea. Again, the algorithm shows when your doctor might order the appropriate imaging tests.

2. If you have a diagnosis of a serious underlying condition, such as cancer that is not cured, a doctor may order an imaging study sooner rather than later. Or for example, if you have severe osteoporosis and developed sudden back pain, an x-ray can show whether you have a compression fracture. Another reason your doctor might order x-rays right away is concern about a serious cause of the back pain because you have other signs or symptoms, such as, for example, fever, unexplained weight loss, or risks for an abdominal aortic aneurysm.

3. If you are willing to undergo an invasive intervention such as surgery or an epidural spinal injection because of the severity of symptoms over a long period of time imaging will be necessary prior to such a procedure.

CONS: Here’s why getting an X-ray right away for non-specific LBP might not be a good idea: 1.

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They don’t help you get better faster. Like we said above, the vast majority of patients are better in days to a month whether they get imaging studies or not. Six good studies that compared routine imaging with no testing for patients with LBP showed that patients did the same regardless of whether they got the tests or not. AND some studies suggested that patients that did NOT get tested actually improved faster.

They pose risks. X-rays and CT scans expose you to radiation which can increase cancer risk. One estimate is that 1200 new cancers were caused by the 2.2 million CT scans done for LBP in 2007. X-rays of the low back have about 75X as much radiation as a chest X-ray. This much radiation can damage reproductive and other organs in both men and women.

Imaging studies often show findings that are or could be unrelated to the back pain. Tests often show changes in the spinal bones or the spaces between them. These findings often are not the cause of your back pain. They can lead to unnecessary worry and the need to do more testing for something that is an incidental finding.

It follows then that working up radiologic abnormalities can expose you to more complications from testing.

Then also, operating on or treating abnormalities may do no good. Patients that have MRIs in the first month of non-specific low back pain are 8X more likely to go to surgery and have a 5X increase in medical costs but DID NOT RECOVER FASTER or better.

Finally, x-rays can be a waste of money as can working-up and treating findings that are not related to your back pain, not to mention complications that might arise from diagnostic and treatment modalities! choosingwisley.com 2014, acponline.com 2014 2