A recent study suggested that many treatments for back pain do not appear to be effective. I am unsurprised. The first reason is that the wrong diagnosis has been made. The second is that the treatment is, actually, ineffective.
Back pain has several causes; pain can come from a number of different structures. It’s no good treating a disc prolapse with a muscle injection. If the pain does not arise from a facet joint then injecting that joint will do nothing. If the issue is a pulled back muscle then manipulation may actually make things worse. And surgery to remove a bulging disc won’t help if the disc is not the problem. MRI scans may help, but you can be sure if a disc bulge is on the left, and all the symptoms are on the right, then that disc bulge is irrelevant. It is difficult, though, to persuade patients that an “abnormality” does not signify.
Thus the first key is – be sure which structure is the source of the pain. I have an algorithm that helps, but is not infallible. I failed to diagnose my own disc prolapse for a couple of weeks because the algorithm pointed me the wrong way. But it’s a start.
The second key is patience. How do you treat a bruise? You treat the affected area with a bit of respect (not a lot) and wait for it to get better on its own. So should you with back pain. 95% get better in four to six weeks – even disc prolapses resolve themselves quite often. Mine did. However there are some symptoms that should prompt the seeking of help; severe pain at night, nerve symptoms (loss of sensation or power in the leg); and especially any disturbance of bladder and bowel control. The worrying causes of back pain are cancer or osteoporosis. The former produces unremitting pain, the latter may have a sudden onset as a bone collapses. The history is vital.
Treating cancer in bones is possible. Treating pain from an osteoporotic fracture is possible, but trying to treat the osteoporosis itself will make no difference. Time will heal the fracture and the pain will go off; anti-inflammatory drugs will help with the pain meanwhile.
I have had dramatic results from injecting anaesthetic and steroids around facet joints. Such success may be gratifying not because it works but because it confirms the diagnosis of facet origin pain. Spinal manipulation is positively dangerous in some circumstances. I saw a patient who had had his neck manipulated when the cause of the pain was a large cancer deposit in one of the vertebrae which had made it vanish on X-ray; he was lucky that the manipulation did not dislocate the spine and transect the spinal cord. I have also seen patients whose disc prolapse has been worsened by a quick tweak. I have also seen a patient who had been diagnosed with polymyalgia (multiple central muscle pains now thought to be due to blood vessel inflammation) whose exacerbations of pain were treated with large increases in their steroid dose. But the cause of the pain was not polymyalgia, but recurrent osteoporotic crush fractures – which the bursts of steroids were helping to create. Folk are ever so keen to have an osteopath or chiropractor manipulate them, but there’s an awful lot of them who go back time after time for repeat treatments because they don’t last (or work).
So the first step is to make sure you have the right diagnosis, and the second is to administer the right treatment for it – or none at all. Nothing can be a treatment. But it’s not easy to persuade someone that nothing is better than something. My rule was – if it’s that painful, rest it, but when it starts to improve get moving ASAP. Bedrest can not only prolong recovery but also lead to chronic problems. Keeping up muscle strength is vital.
There is a story of an old villager in France who had an astounding reputation for correctly identifying wines. He could pick types, origins, even years. Eventually during a tasting competition one of the judges slipped in a glass of water. The old boy nosed the glass, took a sip, swilled it round and spat. He looked puzzled. He had a piece of bread and repeated the process, and then a third time. Eventually he turned to the judges. “I have never been wrong, or beaten by something” he said “but I confess that this has defeated me. I don’t know what it is. But I do know one thing. It won’t sell.”