The Four Stages of Low Back Pain Care and Recovery

Back Rx: A Fifteen Minute A Day Yoga And Pilates Based Program to End Low Back Pain Forever
by Vijay Vad, M.D.

(Page 5 of 6)

Treatments for low back pain fall into four main categories or stages. The vast majority of patients can achieve full recovery with Stage I care. You become a candidate for Stage II care and beyond only if you are among the roughly 20% of low back pain sufferers who do not heal during Stage I. Each additional stage of care is in turn appropriate for a smaller and smaller patient pool.

Stage I Care

Stage I care is for just about everyone with low back pain. It involves a sequenced combination of rest, medications (anti-inflammatories, muscle relaxants, and pain relievers as needed), heat and ice, and gentle rehabilitative exercise. Back Rx is a comprehensive program of Stage I care.

This first stage of care can resolve 80% or more of all low back problems. It should not be bypassed or curtailed, unless surgery is indicated as described on page 17. When other treatments are tried, Back Rx or a similar program of Stage I care should almost always be continued, or resumed as soon as possible afterward, in order to realize their full benefits.

Stage I care may be complemented by traditional physical therapy, osteopathy, medical massage, chiropractic, acupuncture, or some combination of these. For more information on these treatments and how to decide if they're right for you, see the rest of this chapter and Chapter 11.

Stage II Care

For severe, ongoing low back pain that does not respond to Stage I care, Stage II offers three minimally-invasive, nonsurgical procedures:

• In cases of low back pain without leg pain, paravertebral, or trigger point, injections of a saline solution to inflamed, tender areas.

• Selective nerve root epidurals under fluoroscopy, also known as guided epidurals. These injections deliver a carefully calibrated dose of lidocaine and corticosteroid directly to the inflamed nerve that is the source of the pain, as determined with the aid of fluoroscopy. (Fluoroscopy is a form of X-ray guidance.) These injections are used for low back pain with leg pain (sciatica) and have a high, long-lasting success rate when combined with icing and an exercise regimen like Back Rx.

• Facet and sacroiliac (SI) joint injections are also done under fluoroscopy for pain that is deemed to originate from these deep structures. The drawback of these injections is that their effect may be temporary, even if combined with icing and proper exercise.

Stage III Care

For low back pain that does not respond to Stage II care, Stage III care offers three nonsurgical, and two surgical, procedures:

• Radio Frequency Denervation, which halts pain in the facet and SI joints by heating the nerves, which innervates these joints, making the nerves inactive for a couple of years. The procedure can then be repeated.

• Intradiscal Electrothermal Therapy (IDET), which heats the annulus, the hard outer portion of an injured disc.

• Nucleoplasty, which heats the nucleus pulposus, the softer inner portion of an injured disc.

• Micro-discectomy and laminectomy, two very similar surgical procedures in which the herniated portion of a disc is removed.

Stage IV Care

Stage IV care options remain limited, for the present, to spinal fusions, which can be effective in cases of combined back and leg pain. But within the next two to three years artificial disc replacement, which is now being studied in U.S. Food and Drug Administration (FDA) trials, should become widely available. For more information on Stage II to Stage IV care options, and which ones may be appropriate for you, see Chapter 12. For now, keep in mind that well over 95% of all low back pain cases can be healed without surgery. Surgery is indicated only

• To stop the progressive loss of neurological function
• To restore bowel and bladder function
• To end intractable pain.

If you've hurt your back and find that you're losing an increasing amount of feeling and sensation in the leg or elsewhere in the body, that you can't go to the bathroom (this is no joke, but a potentially life-threatening problem), or that severe pain persists no matter what you do, you should put down this book and seek an evaluation from a qualified physician as soon as possible.

The potential for such complications is frightening, and in the immediate aftermath of back injury or reinjury, when the pain is overwhelming, it can be hard not to fear the worst. But once again, please remember that almost all low back pain sufferers can achieve a full and lasting recovery with a sound program of Stage I care like Back Rx, especially if they have the right caregivers in their corner.

A Physician's Help

You can do Back Rx or a similar program entirely on your own. But a physician's expert guidance can help keep your recovery on track and progressing optimally. Primary care physicians are well equipped to manage low back pain, coordinate the efforts of specialist physicians, physical therapists, and other caregivers, and coach you through your recovery. During Stage I care, they can provide the insight and support you need to stick with Back Rx or a similar program long enough for full healing to occur.

The specialist physicians most often involved in low back care are physiatrists, neurologists, anesthesiologists, orthopedic surgeons, and neurosurgeons. Except for physiatrists, specialist M.D.s do not participate much in Stage I care. In later stages of care, a neurologist can be helpful if a person is suffering from foot drop or other signs of neurological weakness. If it becomes necessary to explore surgical interventions such as a discectomy, orthopedic surgeons and neurosurgeons with fellowship training in spinal surgery have state-of-the-art spinal surgical skills. They also have the expertise to offer informed second opinions on prospective surgery. In cases of ongoing severe pain, especially pain that persists after surgery, anesthesiologists with pain management fellowship training should be consulted.

The first consultations with specialist physicians should occur within six months of injury, if possible. After six months, healing becomes a lot harder and the prognosis for full recovery from a low back problem becomes less favorable.

As primary care physicians for the musculoskeletal system and specialists in physical medicine and rehabilitation, physiatrists can play a healing role at every stage of low back care. All physiatrists receive extensive training in conservative nonsurgical care for the low back. Additional subspecialty training in physiatry, such as a fellowship in spine and sports medicine, can be particularly useful in later treatment stages, because it provides expertise in minimally invasive, nonsurgical spinal treatments combined with proper rehabilitation.

All things considered, in the event of a low back problem you should probably turn first to your present primary care physician and his or her referral network. Someone who knows you and your medical history, and whom you trust and feel comfortable with, has a better chance of getting your recovery in high gear quickly and managing it smoothly than a doctor who is meeting you for the first time.

If you do need to find a doctor from scratch, whether a general practitioner or a specialist, the best way to find any good caregiver is through word-of-mouth recommendations from people you trust. You can also learn about different medical specialties and find referrals on the websites of physicians' groups. At the end of the book you'll find an appendix with a list of organizations and websites that can help you with your search.

Other Caregivers

In addition to general practice and specialist M.D.s, a number of other caregivers treat low back pain, including physical therapists, osteopaths, massage therapists, chiropractors, and acupuncturists. Whereas M.D.s and physical therapists are said to practice conventional medicine, the other caregivers are often said to practice integrated medicine. I find these labels a little awkward. Every good healer wants to take an integrated, holistic approach to patient care. "Leave no stone unturned to help the patient" should be every caregiver's motto.

Granted that, and granted that equally good healers can have very different credentials, you want to make sure that the caregivers you go to have the appropriate credentials for their different fields. Keep in mind that whereas conventional medicine regularly tests its practices in controlled studies, most of integrated medicine has not yet been documented with the same rigor. Of the common alternatives to conventional medical care for the low back, only massage therapy and osteopathy have so far been proven effective in clinical trials. There is other, if less rigorous, medical evidence for the value of acupuncture and chiropractic, however, and I have seen many patients helped by each of them.

To find a good practitioner of one of these treatments, ask around. Personal recommendations from people you know and trust are the best way to find a good healer. After that you have to follow your instincts. Everyone is different, and every case of low back pain is different. As long as you are making an informed choice, you should feel free to pick and choose the therapies that seem best suited to your individual needs, perspective, and lifestyle. The proof is then in the pudding. A therapy may be very appealing for one reason or another, and it may help other people. But if it doesn't help you over the course of a few weeks or months, you should abandon it and move on to something else. As with conventional medical care, you should try to find the right integrated medical care for your case within six months of your injury. After that point, healing becomes much harder, no matter what the treatment is.

I'll have more to say about these varied treatment options in Chapter 11. Here I would only caution that where chiropractic is concerned, you should not have any high-velocity manipulations of the head and neck. They can cause spinal cord injuries and strokes. It's not a high risk, but why take the chance that you'll be the one person in many thousands who is crippled or killed?

Copyright © 2004 Vijay Vad, M.D.

About the Author

Dr. Vijay Vad is a sports medicine physician and researcher specializing in minimally invasive arthritis therapies at the prestigious Hospital for Special Surgery in Manhattan and a professor at Weill Medical College of Cornell University. He is also the physician for the PGA golf tour and the ATP tennis tour.