There’s no single treatment regimen for back pain. But, considering that up to 90% of cases of neck and back pain resolve by themselves in under six weeks, you may not need treatment at all.
When the cause of your back pain is clear (for example, if there’s a diagnosis of malignant disease, spinal malformations or spinal injury), treatment strategies are well-defined.
Trial and error
However, for non-specific back pain, it can take a period of trial and error to find the right treatment.
For decades, manual treatments (e.g. chiropractic, osteopathic manipulation, and physical therapy), medical treatments (e.g. injections and medications such as opioids), and surgery have been the mainstay in terms of back pain treatment. But the trend today is an integrative approach in which a variety of specialists are involved in treating the problem.
The goal is to assist you in doing everything possible to reduce or remove the pain, and to avoid surgery.
Two treatment strategies are currently used, says one of the world’s leading back pain experts, Prof Chris Maher of the University of Sydney, Australia. A stepped approach, beginning with simple care, is progressed if you don’t respond to initial treatment. Simple risk prediction methods are then used to individualise the amount and type of care provided.
He notes that the overuse of imaging, opioids and surgery remains a widespread problem. This is echoed by three papers published in The Lancet in which the authors found that there’s an over-reliance on scans, surgeries and opioid prescriptions in treating a problem that could be more effectively addressed through self-management and less invasive physical and psychological therapies.
Can your GP help?
Yes, your GP can evaluate, diagnose and reassure you that you don’t have a serious disease. He or she can also give you something for the pain and refer you to a specialist.
But your GP won’t always have a quick fix for simple back or neck pain. In fact, American pain specialist Dr David Glick says the number-one reason for chronic back pain, or why acute back pain becomes chronic, is failure to diagnose and treat it properly.
See a specialist if the treatment prescribed by your GP doesn’t help to resolve your pain.
Back pain specialists
Many specialists are involved in treating back pain. If you’re unsure which one is right for you, your GP can help to refer you to the right doctor after an initial assessment. The list of specialists includes:
- Orthopaedic surgeons
- Physical and occupational therapists
- Physiatrists (medical doctors who specialise in physical medicine, rehabilitation, and pain medicine)
- Sports medicine specialists
You may be your own best doctor. You might already know that slouching in your office chair is causing neck pain, or that constant stress is causing tense muscles. These are problems you can fix yourself by changing your behaviour and/or environment.
Guidelines for the treatment of acute, sub-acute and chronic lower back pain
In 2017, the American College of Physicians released new guidelines for the treatment of lower back pain (LBP).
They recommend that if you’ve had LBP for less than three months, you should avoid painkillers (especially painkillers that contain addictive substances such as codeine) and rather use other modalities such as massage, heat, acupuncture, exercise, yoga or physical therapy as a main course of treatment.
They offer the following information in terms of quality of evidence for the different types of treatment:
TYPE OF TREATMENT
QUALITY OF EVIDENCE
Sub-acute lower back pain
Massage, acupuncture or spinal manipulation
Non-steroidal anti-inflammatory drugs or skeletal muscle relaxants
Chronic lower back pain
Exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction
Tai chi, yoga, motor-control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioural therapy, spinal manipulation
Chronic lower back pain where the above therapies didn’t help
Non-steroidal anti-inflammatory drugs as first-line therapy, or tramadol (one of the active ingredients found in Tramacet tablets) or Duloxetine (an antidepressant) as second-line therapy
Clinicians should only consider opioids (medication that act on the nervous system to relieve pain, including OxyContin, Vicodin and medication containing codeine, fentanyl or morphine) as an option in patients who have failed the afore-mentioned treatments and only if the potential benefits outweigh the risks for individual patients, and after a discussion of known risks and realistic benefits with patients.
Over-the-counter pain medication
New research shows that simple analgesics such as paracetamol are no better than placebo for relieving acute LBP in either the short or longer term.
However, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can reduce muscle and joint inflammation, and thereby help treat back pain. They’re available in tablet form, but also as gels, sprays and plasters that can be applied directly to the affected area.
Consult your doctor about the long-term use of even non-prescription medications, especially NSAIDs, as they can have significant side effects. For example, they can be dangerous if you have hypertension, cardiac or renal disease, or a history of peptic ulcer.
Transcutaneous electrical nerve stimulation (TENS) acts by interfering with the transmission of pain signals. Electrodes are placed on your skin, near the painful area, and a mild electric current is passed through them.
TENS may relieve sciatica pain, but usually provides little relief from chronic back pain. TENS therapy is most effective when administered at the correct frequency and site. Speak to your physiotherapist for more information.
Physical therapy is aimed at preventing injuries, relieving pain and promoting healing. Heat and cold applications, TENS, ultrasound and iontophoresis (where anti-inflammatory steroids are delivered through the skin via an electric current) as well as massage performed by a physical therapist could be offered.
Doing simple hamstring stretches for lower back pain is extremely effective, and other muscle strengthening exercises should also form part of your rehabilitation.
In some cases, hydrotherapy is recommended. These exercises are done in a heated swimming pool where the warm water helps to support the damaged tissues, providing resistance for the exercises.
Some doctors recommend using a back brace to help support the spine. A brace may help prevent injuries for workers who have to lift heavy objects, but using a brace too often can weaken the core muscles that support the back, making back pain problems worse.
Talk to your doctor about the pros and cons.
Adjusting your spine can provide relief from LBP. But it’s possibly as effective as exercising, taking pain relievers and/or sleeping on a firm mattress. With spinal manipulation, hands are used to apply controlled force to a joint of the spine.
Manipulation should only be carried out by an appropriately trained doctor, physiotherapist, osteopath or chiropractor, and must be done in consultation with a neurosurgical or orthopaedic spine specialist.
X-rays, CT scans and MRIs for back pain diagnosis
Specialists agree that, unless your pain is severe, it worsens or persists beyond six weeks, is the result of an accident or there’s at least one other red flag that causes back pain, imaging tests such as X-rays, CT scans and MRIs won’t be of much use.
These tests could just point to normal disc degeneration, which is part of the ageing process, and cause you to worry unnecessarily.
There are three main types of back surgery:
- Spinal fusion, a procedure that permanently joins two or more bones in the spine
- Discectomy, where a portion of a disc is removed to relieve pressure on a nerve
- Decompression surgery (laminectomy), which relieves pressure on the nerves by removing the lamina (the back part of the vertebra that covers the spinal canal)
Back surgery should always be a last resort.
What about new and less invasive procedures?
The era of less invasive surgery is here and smaller keyhole incisions are replacing large surgical cuts. In terms of back surgery, these less invasive techniques include:
- Endoscopic discectomy. This technique employs a disposable scope that the surgeon inserts through a small incision. The protruded disc that’s compressing the nerve is then removed, using specially designed instruments.
- Vertebroplasty. This involves the injection of bone cement into fractured vertebrae. The hardened cement seals and stabilises the fracture, and relieves pain. If you suffer from severe pain because of a compression fracture, you will be considered for this procedure, especially if you have difficulty standing and walking.
- Kyphoplasty. This refers to the insertion of a “balloon” to expand a compressed vertebra as well as the injection of bone cement.
This involves the use of weights or motorised devices to realign or stretch the spinal column into alignment. Clinical studies have shown that traction isn’t beneficial in the treatment of back pain in the first few weeks. In fact, it’s an outdated technique that should only be done under the supervision of a trained medical professional.
New research in treatment for back pain
Back schools were developed in Sweden and involve groups of patients who go through lessons in back care, posture, body mechanics, and back exercises to prevent long-term back problems.
Despite being hugely popular in the USA, back schools seem to have little effect on chronic back pain and are less frequently used in Europe.
Nerve block and cortisone injections
Epidural steroid and cortisone injections can reduce pain originating in the spine for anything from one week to up to one year. These injections are especially helpful in allowing people with back pain to progress through rehabilitation.
This refers to a neurosurgical procedure that selectively destroys problematic nerve roots to the facet joint, preventing the pain signals from getting to the brain. It provides lasting pain relief for around 50% of patients but is a high-risk procedure.
Stem cell therapy for back pain
Stem cell therapy is showing promise in providing long-term back pain relief and preventing the need for invasive surgery in up to 77% of patients. The treatment is focused on musculoskeletal applications to heal, repair and regenerate injured or damaged tissue.
During stem cell therapy, your own stem cells are removed from your bone marrow and re-injected into painful and damaged spinal discs. It’s said to help reduce inflammation in the spine and stimulate the creation of new tissue in the spinal discs. The procedure, which is performed in an office setting under local anaesthesia, takes around 45 minutes and promises to decrease pain at the level of injury.
Research studies are showing positive results. In South Africa, the SA Stem Cell Institute provides stem cell therapies.
Yoga for back pain
Research shows that yoga can ease moderate to severe chronic LBP.
Researchers found that participants with chronic lower back pain who completed a 12-week yoga programme (consisting of two 60-minute instructor-led yoga sessions per week, with home practice sessions encouraged) had better scores on a disability questionnaire, showed improved pain intensity scores, and used less opioids. They practised hatha yoga, which involves yoga postures and movement sequences as well as regulated breathing and mindfulness meditation.
Another study showed that study participants who practised lyengar yoga, which uses blocks, belts and other props to help individuals perform classic yoga poses, experienced reduced pain, functional disability and depressive symptoms.
Massage may help for back pain
Complementary and alternative (CAM) therapies such as massage, acupuncture, manipulation and mobilisation may help immediately or shortly after treatment, but their benefits seem to fade over time. As such, these therapies may not be a solution for chronic back pain.
However, a 2017 Kentucky University Pain Research and Outcomes Study showed that massage therapy may provide lasting relief for chronic LBP. Participants reported between 50% and 75% improvement over various periods. Study participants went to 10 sessions over a period of 12 weeks, and the massage practitioners were free to design individualised programmes.
The researchers believe that massage directly reduces inflammation in the muscles. It seems to work particularly well for:
- Individuals aged 49 and older (these participants showed more improvement than younger patients)
- Obese individuals (but the gains didn’t last)
Interestingly, participants taking opioids were two times less likely to experience any meaningful changes.
Document-based care for back pain
Document-based care (DBC) was developed in Finland over the last two decades. It refers to a set of scientifically proven functional rehabilitation treatment protocols and equipment specifically designed to address musculoskeletal conditions.
The DBC Active Spine Treatment System is used to treat long-term back and neck problems, including problems that produce severe pain. If affected individuals carry out controlled, targeted exercises correctly, their muscle endurance, strength and range of motion improve. Pain can also be reduced, thanks to the reduction of fear and dispelling of common misconceptions regarding chronic pain (among other things). Benefits extend even to the most severe cases.
Two key elements are combined in the DBC functional rehabilitation programme: progressive physical conditioning and cognitive behavioural treatment.
The DBC network provides treatment in more than 22 countries on five continents, with an extensive network of treatment centres in South Africa. Many South African medical aids will offer DBC treatment as part of their packages.
Reviewed by Dr Suzette Oelofse and Dr Lienka Botha, General Practitioners at Fx Health Cape Town, April 2018
- Chris Maher et al. Non-specific low back pain. The Lancet. Volume 389, No. 10070, p736–747, 18 February 2017.
- Leigh Atkinson and Andrew Zacest. Surgical management of low back pain. Medical Journal of Australia. Med J Aust 2016; 204 (8): 299-300. | doi: 10.5694/mja16.00038.
- Amir Qaseem et al. Non-invasive treatments of acute and subacute chronic low back pain in clinical practice. Annals of Internal Medicine. 4 April 2017.
- Saragiotto BT et al. Paracetamol for low back pain. Cochrane.org. 6 June 2016.
- Document Based Care Back and Neck Treatment, DBC Clinic.
- Complementary and Alternative Therapies for Back Pain II. Rockville (MD): Agency for Healthcare Research and Quality (US); 2010 Oct.
- Dr. Erik J. Groessl et al. Yoga for Military Veterans with Chronic Low Back Pain: A Randomized Clinical Trial, American Journal of Preventive Medicine, July 20, 2017.
- Williams K et al. Evaluation of the effectiveness and efficacy of Iyengar yoga therapy on chronic low back pain. Spine (Phila Pa 1976). 2009 Sep 1;34(19):2066-76. doi: 10.1097/BRS.0b013e3181b315cc.
- Elizabeth Adams. UK Researcher Purports Massage Therapy Benefits for Chronic Low Back Pain. University of Kentucky website. 12 April 2017