Understanding Back Pain -- Diagnosis and Treatment

How Is Back Pain Diagnosed?

Before a doctor can begin treating back pain, he or she may do tests to diagnose what is causing your problem. Unless you are totally immobilized from a back injury, your doctor probably will test your range of motion and nerve function and press on your back to locate the area of discomfort.

Blood and urine tests may be done to be sure the pain is not caused by an infection or other systemic problem. X-rays are useful in pinpointing broken bones or other skeletal defects. To analyze soft-tissue damage such as disk herniation, magnetic resonance imaging (MRI) scans may be needed. A CT scan can be done instead for those who cannot have an MRI. X-rays and imaging studies are not usually indicated for first-time back pain caused by an overuse type injury and are generally used only for checking out ongoing pain, direct trauma to the back, back pain with fever, or nerve problems such as weakness or numbness in the arms or legs. To determine possible nerve or muscle damage, an electromyogram (EMG) can be useful.

Unfortunately, there is not always a direct correlation between the findings on imaging studies and the amount of back pain. Many people have findings on CT scans and MRI, yet do not have back pain.

What Are the Treatments for Back Pain?

Back pain treatment goals are pain relief and restored movement. The basic treatment for relieving acute back pain from strain or minor injury is to modify your activities. An ice pack can be helpful, as can acetaminophen (Tylenol), aspirin or another nonsteroidal anti-inflammatory drug (NSAID) to reduce pain and inflammation. Never give aspirin to a child younger than age 19, as it increases the risk of Reye’s syndrome. After the inflammation subsides, applying heat can help soothe muscles and connective tissue.

Bed rest, which used to be advised for the treatment of back pain, is not only unnecessary for most cases of back pain, but it may actually be potentially harmful. It may slow recovery and cause new problems. In most cases, you will be expected to start normal, nonstrenuous activity (such as walking) within 24 hours to 72 hours. After that, controlled exercise or physical therapy may be helpful. Physical therapy treatments may employ massage, ultrasound, whirlpool baths, controlled application of heat, and individually tailored exercise programs to help you regain full use of the back. Strengthening exercises for both the abdominal and back muscles helps stabilize the spine. You can help prevent further back injury by learning -- and doing -- gentle stretching exercises and proper lifting techniques, and maintaining good posture.

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If back pain keeps you from normal daily activities, your doctor can help by recommending or prescribing pain medications. Over-the-counter painkillers such as acetaminophen (Tylenol), aspirin, or ibuprofen (Motrin, Advil) can be helpful. Your doctor may prescribe prescription strength anti-inflammatories/pain medicines. For severe pain, he or she may prescribe combination opioid/acetaminophen pain medications such as hydrocodone/acetaminophen (Vicodin) or oxycodone/acetaminophen (Percocet). Some doctors also prescribe muscle relaxants. But beware, pain medications and muscle relaxants affect the brain, and often cause drowsiness and dependence. Other medicines such as antidepressants and anticonvulsants are sometimes prescribed to help with pain related to irritated nerves. Although sometimes used, steroids taken by mouth are not recommended by the American College of Physicians (ACP) for the treatment of acute low back pain.

When back pain is chronic, pain modifying medications, such as the antidepressant Cymbalta (duloxetine), may be helpful. Cymbalta, a serotonin-norepinephrine reuptake inhibitor, or SNRI, is FDA approved for the treatment of chronic pain related to the muscles and skeleton, including pain from arthritis and chronic lower back.

If your primary doctor isn't able to help you control back pain, he or she may refer you to a back specialist or a pain specialist. Sometimes, these doctors will use injections of steroids or anesthetics directly into the back to help control the pain. In cases where there is a herniated disc or pinching of the nerve from the spinal cord, surgery may be indicated.

A medium-firm mattress has been shown to be helpful in the treatment of chronic back pain.

For those patients with long-standing back pain and nerve damage, some newer treatments have been developed recently to help with the treatment of pain. One of these is radiofrequency ablation, a process of delivering electrical stimulation to specific nerves to make them less sensitive to pain, or by delivering enough electricity to actually destroy the nerve to prevent further pain. More research is needed to see if this approach is effective.

Some physicians advocate using a transcutaneous electrical nerve stimulator (TENS), although whether TENS is clearly helpful for back pain has not been resolved. Electrodes taped to the body carry a mild electric current that may help relieve pain. TENS is not painful, and it may be effective therapy to mask pain such as diabetic neuropathy. However, TENS for chronic low back pain is not recommended, according to the American Academy of Neurology (AAN), because its effectiveness has not been proven.

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In cases of persistent pain from extreme nerve damage, rhizotomy -- surgically severing a nerve -- may be necessary to stop transmission of pain to the brain. Rhizotomy can correct the symptoms caused by friction between the surfaces in a spinal joint, but it doesn't address other problems, such as herniated discs.

Chiropractors have a role in the treatment of back pain. The U.S. Agency for Healthcare Research and Quality recognizes spinal manipulation by chiropractors and osteopaths as effective for acute low-back pain. Its effectiveness for treating chronic back pain is less well-established. Some researchers suggest that early chiropractic adjustments for acute back pain may prevent chronic problems from developing. Other doctors warn against some chiropractic manipulations, particularly those that involve rapid twisting of the neck.

Osteopathic treatment is likely to combine drug therapy with spinal manipulation or traction that may be followed by physical therapy and exercise.

Research has shown that acupuncture may bring relief for many chronic back pain sufferers. There doesn’t seem to be any difference, however, between the relief brought on by acupuncture as opposed to simulated acupuncture. More research is needed to find out why both techniques are effective. Acupuncture can be used alone or as part of a comprehensive treatment plan that includes medications and other therapies.

If you consult a psychotherapist for cognitive behavioral therapy (CBT), your treatment may include stress management, behavioral adaptation, education, and relaxation techniques. CBT can often lessen the intensity of back pain, change perceptions about levels of pain and disability, and even lift depression. The NIH considers CBT useful for relieving low back pain, citing studies that show CBT to be superior to routine care and placebo. Other comprehensive behavioral programs have shown similar success, with participants able to lessen the amount of medication they needed while improving their outlook and pain-related behavior.

If lower back pain is related to muscle tension or spasm, biofeedback may be effective for lessening pain intensity, decreasing drug use, and improving quality of life. Biofeedback may help you train your muscles to respond better to stress or movement.

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The Alexander Technique, Pilates, and the Feldenkrais Method are all specialized forms of body work that help you learn to move in a more coordinated, flexible, and graceful manner. More research is needed to see if they can help reduce pain. Some of the postures of yoga may help improve flexibility, strength, and sense of balance. Yoga is good for stress reduction and may help with the psychological aspects of pain.

Aquatic therapy and exercise can also improve flexibility and decrease pain for some with chronic low back problems. The unique properties of water make it an especially safe environment for exercising a sore back; it provides gentle resistance, comfort, and relaxation.

For most chronic back pain patients, surgery is a treatment of last resort. The decision for surgery for back pain without nerve damage should only be made after non-surgical treatment has failed and the risks and benefits of surgery have been fully discussed.

WebMD Medical Reference Reviewed by Jennifer Robinson, MD on July 16, 2015

Sources

SOURCES: 

Oh, W.; Shim J. The Clinical Journal of Pain January/February 2004. 

Friedman, F. Outwitting Back Pain: Why Your Lower Back Hurts and How to Make It Stop, Lyons Press, 2004. 

News release, FDA.

American College of Physicians.

UpToDate.

American Academy of Neurology.

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