Back Pain Treatment II

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What is the ideal patient process, and what problems do patients and professionals face when treating back pain? 

Elaine Borgen, Psy.D.:

Elaine Borgen is a psychologist in the Division of Preventive and Behavioral Medicine at UMass Medical Center, in Worcester, Massachusetts.

By the time a patient sees me they usually have seen a variety of specialists such as orthopedists, neurologists, rheumatologists, etc. and over a significant number of months or more often, it's been years. The sooner I start working with a patient to manage their back pain, the easier it usually is to intervene and have a positive effect on their level of functioning and quality of life. These early interventions can often help ward off deeper levels of depression and functional impairment, including disability and narcotic dependence.

One of the challenges is that there isn't any one right answer or approach to managing chronic back pain. I tell my patients that it's like taking the pieces of a puzzle and figuring out how they all fit together. Unfortunately, you might not have all of the pieces. No two patients are exactly alike; they may be similar, but not exact. Sometimes patients with chronic pain feel stigmatized or labeled as having ulterior motives for not getting better. In the rare case when this is true, the providers can actually use this as an intervention. With this said, each patient deserves an individualized treatment plan with his or her specific needs in mind. As a psychologist, this is something that I can help the physicians to do.

As a psychologist, I can also provide psychosocial assessment on a variety of issues including risk of depression and anxiety, risk of substance/narcotic abuse as well as assessing readiness to change. Motivational interviewing is a technique originally developed for use with substance abuse populations, but has been found useful for helping a variety of patient populations to prepare for and make behavioral changes (e.g. learning to accept, live and cope with chronic back pain). There are a variety of psychological assessment tools available to assist in this process.

What is the ideal patient process, and what problems do patients and professionals face when treating back pain? 

Brenda Hellmann, RNC/ NP, MSN:

Brenda Hellmann is a Nurse Practitioner at Harbor Medical Group in Danvers, Massachusetts.

Prevention is always better than a cure. People should be in better physical shape. Utilization of regular exercise, good shoes, and good body mechanics go a long way towards a healthy lifestyle. If someone does injure their back, the appropriate course would be to ice it, and to use an adequate amount of non-steroidal anti-inflammatory medications two to three times a day with food. Stretching is also an essential component to good physical health and wellbeing. It is important to pay attention to the things and activities that make pain worse, and to avoid things that tend to aggravate their situation. For example, people with back pain should not sit for prolonged periods of time. If pain gets progressively worse, is unresponsive to self-care treatments within 48-72 hours, becomes a recurrent problem, begins to spread into their legs, becomes so severe that patients have difficulty moving, or begins to interfere with a patient's ability to go to the bathroom, it is important to see a healthcare provider immediately.

People don't start at square one; they don't ice their injuries or take an appropriate course of anti-inflammatory medication. By the time a patient comes to see me with pain, it has been three or four days and the inflammation and pain have often spread and intensified. If patients wait to consult their healthcare providers, injuries and pain can worsen and interventions take longer to be effective.

The fact that many people are not physically fit and/or are overweight causes many problems to become chronic. A lot of times, people do not buy into the therapies and believe that injures will resolve themselves. Taking care of your back is a lifelong commitment, and should be a priority even when you are not experiencing pain. Prevention, early intervention, and education are key to healthy back care.

Many people respond well to back care therapies. The interventions that are more difficult involve lifestyle changes: losing weight, stretching, wearing good shoes, sleeping on a good mattress, exercising. It can be difficult to convince people to take responsibility for their back health, but ultimately, a patient's commitment to health will dictate the course of their life.

What is the ideal patient process, and what problems do patients and professionals face when treating back pain? 

Joel Hellmann, MD:

Dr. Hellmann works for a large health insurance company and lives in Massachusetts.

The ideal process for an educated back pain patient would be to self-treat for a couple of days by appropriately applying ice at regular intervals, appropriately using over the counter anti-inflammatory medicine, and maintaining an appropriate activity level within pain tolerance. If there are signs of improvement with these self-care techniques, the back pain patient would continue to self-treat, and gradually increase a tolerable level of activity, and eventually add activities such as stretching, strengthening, and appropriate exercise. If there was no improvement after a few days of self-care, however, or if the patient had concerns of any kind, it would be important for that person to contact their healthcare provider for a professional evaluation. Immediate medical attention would need to be paid to back pain that was caused by a specific trauma, that radiates to any place other than the back (such as the legs), that causes numbness or tingling, that triggers a change in bowel or bladder habits, or that is so severe that it cannot be relieved.

One of the key elements of back care is that patients are educated about the back and have a clear understanding of what it will take to get better. Part of this understanding includes being realistic about what they are and are not able to do, understanding that all treatments for back pain take time to work, understanding what activities are and are not appropriate as well as the rate at which it is reasonable to expect activity level to increase. It is important that patients be aware of the precautions that need to be taken in order to have and maintaining a healthy back.

Today's society puts pressure on both the patient and provider - providers are expected to both educate and treat patients in discreet periods of time, and patients are expected to return to a normal and productive life as quickly as possible. These pressures challenge our abilities as providers and patients to both provide adequate education as well as allow the body to heal completely. From my perspective this is the most important potential pitfall. There are no shortcuts. Patients must take the time to heal if they want to avoid recurrent and worsened injuries.

We would all like quick relief, a quick cure, and a rapid return to our normal lives, but it simply does not exist for most patients. Back pain patients must rest. They must stick to activities within the limits of their pain, avoid activities known to exacerbate their back pain, stick to a schedule for icing the back for the first 72 hours, and appropriately use over the counter, non-steroidal, anti-inflammatory drugs (NSAIDs) - such as ibuprofen. These recommendations are the hallmarks of initial management and care of muscular injuries of the back (which most are). When conservative care and self-management is recommended, however, people may be disappointed and think that they are not getting appropriate medical care.

In my experience, the people who recover appropriately tend to listen well, ask appropriate questions, have the ability to understand the information that is being given (i.e. No inherent language or comprehension issues/barriers), and do not expect medication to be the quick or the only aspect of care. Back problems can recur and can lead to frustration. In my experience, people with recurrent back problems are often be less patient and want more aggressive therapies - particularly medication. Back injuries require time to heal and the best recommendation that I could make is to be patient with the process and follow the recommendations of your healthcare provider.