A spinal injection to treat back pain that is linked to more than two dozen deaths in the recent meningitis outbreak — due to contamination of the drug with a fungus — has focused the spotlight on an oft-used steroid treatment that’s only modestly effective at reducing pain in most patients. This raises the question: Is there a better treatment for the 10 percent of Americans affected by low back pain?
No doubt, spinal injections that block inflammation, over-the-counter and prescription pain relievers, and physical therapy can bring considerable short-term relief, and often back pain heals on its own. But for those with lingering symptoms, back pain cures remain elusive.
“Back pain, unfortunately, isn’t something we’re very good at treating,” said Dr. Steven Atlas, a primary care internist and director of the Primary Care Research & Quality Improvement Network at Massachusetts General Hospital. That’s despite the fact that magnetic resonance imaging scans can precisely pinpoint disk, nerve, and other spine abnormalities, which has led surgeons to perform increasingly complicated procedures to fix several things at once. They’re doing 15 times more complex back surgeries today than a decade ago, according to recent research published in the Journal of the American Medical Association. Doctors have oversold the potential for a lasting cure from any treatment, Atlas said, when they instead should be emphasizing “finding the most effective management for the condition.”
A growing body of research suggests that the best way to manage back pain is to get up and move around, stretch and engage in resistance training to increase flexibility and core body strength, and find ways to psychologically deal with the daily discomfort.
“A lot of patients have to accept the fact that they’re probably going to have back pain off and on for the rest of their lives,” said Ann Webster, a health psychologist at the Benson-Henry Institute for Mind Body Medicine. She teaches patients in 10 weekly group and individual sessions various relaxation techniques. The sessions, which are covered by insurance, help patients to stop tensing muscles when they feel pain, which is an instinct that ultimately leads to more discomfort.
“I teach meditation, guided imagery, and mindfulness to get them to acknowledge the pain without anger,” she said. She also teaches yoga, even to those whose back pain has forced them to use walkers or wheelchairs.
The training program does not necessarily lead to less back pain, but most are not bothered as much by it.
. . . Surgeons are doing 15 times more complicated back surgeries today than they were a decade ago . . .
“They change their perspective,” said Webster. “They feel more optimistic because we’ve removed the emotional component associated with the pain.”
Studies measuring the pain-reducing benefits of mental health techniques have yielded mixed results, and exercise programs are “slightly effective at decreasing pain and improving function” compared with no treatment or conservative treatments such as over-the-counter painkillers, according to a 2005 review of 61 clinical trials conducted by the Cochrane Collaboration, a nonprofit research group.
But some specialists contend that the biggest benefits occur when physical therapy, exercise, and relaxation techniques are combined into a single program tailored to the individual patient.
That’s the tack taken by Spaulding Rehabilitation Network in Medford, where patients participate in education seminars, therapy sessions, and exercise classes for several hours, twice a week for six weeks, to learn the basics about caring for their backs. They’re given stretches, strength training moves, and a home workout plan and learn the proper techniques for rising from a chair, lifting grocery bags, and other functional activities.
“We typically get patients who don’t respond to physical therapy or painkillers,” said Dr. Alec Meleger, medical director of the rehabilitation program, “and 87 percent of our patients achieve their functional goals,” which may be to return to work, start playing tennis again, or walk unassisted. While some participants experience a significant reduction in their daily pain, becoming pain-free isn’t the ultimate goal of the program, said Meleger. It’s to get them back to the daily routine they had before the back pain started.
After making twice-weekly visits to Medford for three weeks, Sandra Edwards said she wakes up only once a night from her back discomfort instead of every hour or two. “It’s brought a big change in my quality of life,” said Edwards, 45, from the Worcester area, who suffered low back injuries from two car accidents in the past six years.
When she doesn’t make the hour drive to Medford, Edwards practices what she’s learned at home.
“I do my stretches, train with exercise bands, and apply ice or heat the moment I feel a twinge before it gets really bad,” she said. She also does self-massage using foam rollers and makes a point to take daily walks around her neighborhood. “I realize I’ll have to do this for the rest of my life,” she said.
New England Baptist Hospital’s “back boot camp” offers a program that ranges from a few sessions up to a month. It is geared more toward those with milder back pain who are highly motivated to increase their fitness and join a gym after the program. Both programs are covered by insurance, but patients have to meet co-payments ranging from $15 to $40 for each visit.
“We talk a lot about self-efficacy,” said Dr. Carol Hartigan, a physiatrist at the hospital who designs tailored rehabilitation plans for back patients. “People can become very fearful of moving when their back hurts, but we give them permission to use their bodies.”
Patients are initially evaluated to see how fast they can walk, how far they can stretch, and how much they can lift with their back muscles using a weight machine, to set clear fitness goals. Studies performed by Hartigan and others suggest that the program leads to less pain and improved function that lasts for up to two years.
“A big part of the response is felt to be related to the education component,” said Hartigan, “that pain is safe, that hurt does not equal harm, and that moving normally and exercising in the setting of pain is safe and advisable.”
Still, some patients may find that despite their best efforts, they are left with unremitting agony that requires surgery for some level of relief.
After nearly completing the Spaulding program, Sean Sullivan, 44, a Medford resident, said he’s thinking about having surgery to fix the pinched spinal nerve that is causing pain to radiate down his leg.
“I’ve been trying to avoid surgery,” he said. “But it helped me back in 1997 before my back got worse again a few years later.”
Surgery won’t cure back pain even in those with clearly defined mechanical problems: a ruptured disk, scoliosis, or spinal stenosis, which causes a pinched nerve due to a narrowing of the nerve canal from arthritis.
“I can’t make anyone’s back 18 years old again with surgery,” said Dr. Frederick Mansfield, an orthopedic spine surgeon at Massachusetts General Hospital.
He typically suggests surgery if patients have clear anatomical problems that could be causing their pain — though abnormalities that show up on an MRI are not always the pain trigger — and if they’re not getting enough relief from conservative treatments such as painkillers. Only 30 percent of his patients, he said, find that occasional spinal steroid injections work for them long-term.
With surgery, Mansfield added, patients, in the best-case scenario, find that their pain goes from an 8 or 9 — with 10 being intolerable — down to a 3, and that the benefits last for several years. Some have more modest declines in pain or find that their pain returns after just a year or two.
Others experience no improvement from surgery.
“About 85 percent of my patients with spinal stenosis are satisfied with the results,” Mansfield said, “but the rest experience no decline in their pain or, in a small percentage of cases, may have more pain if they develop an infection or scar tissue, which can be completely unpredictable.”
Minimally invasive spine surgeries — which involve an inch-long incision and are performed through an endoscope — have been growing in popularity. They reduce hospital stays from several days to one or two and reduce recuperation time from six weeks down to two or three, according to Mansfield. A 2011 study published in the journal Spine that examined data from more than 100,000 surgery patients found that the minimally invasive technique was associated with fewer post-operative infections compared with open procedures with much larger incisions. There’s not enough evidence yet, however, to conclude that the technique offers better pain reduction or longer-lasting results.