Back Pain Treatment I

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What is your approach to a patient with back pain and what are the most important things all back pain patients should know? 

Elaine Borgen, Psy.D.:

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

When treating back pain, most of the medical profession focuses on diagnosis and treatment with medical intervention (e.g. prescribing medication, injections, surgery, physical therapy, etc.). I try to provide patients with behavioral tools that THEY can use on their own, anytime, anyplace. I try to help empower patients to learn to take a self-management approach to their back pain. I always make it clear that these techniques are not meant to replace medical interventions but rather to compliment them.

When patients first realize that they are experiencing back pain "that won't go away", they typically experience a variety of responses including: denial (there must be a cure), anger (externalizing the blame and/or cause) and depression (a sense of loss regarding their previous way of life). My job is to help assist them through the process of accepting the responsibility for managing their pain experience and becoming ready to do something about it. I try to help them understand that by accepting the pain, they're not giving in to it, but rather learning to control the pain!!

This includes:

  • Understanding how the use of relaxation and self-hypnosis techniques affect their experience of pain.
  • Cognitive techniques aimed at managing a patient's tendency to "catastrophize" and worry themselves into deeper levels of depression or anxiety and pain.
  • Coaching regarding managing lifestyle factors such as sleep, use of stimulants (caffeine and nicotine), exercise and a healthy diet.

It's really a "whole life approach" and that's why our program is called "Living Well with Back Pain". It's not meant to cure the pain, but rather to help a patient and their family live better despite the back pain. And when surgery is necessary, I help patients to prepare for surgery by altering their lifestyle, such as by smoking cessation, managing anxiety and using self-hypnosis techniques to promote a speedy recovery with the use of fewer narcotics.

These are the "realities" that all back pain patients should know:

  1. Unless you're one of the minority that surgery can "cure", your chronic back pain is unlikely to ever go away completely.
  2. There are things that you can do to decrease your pain and its emotional side effects.
  3. Pain medications only work for so long and only does so much (same with injections). Most other treatments have side effects. There are ways to manage pain without negative side effects, and to feel more in control and less out of control because of the pain, while also improving quality of life.
  4. Learn to be your own advocate and ask for what you need. No one else can tell you what you are feeling in your body. You are the expert of your experience, but you need to effectively communicate this to your providers. People experience "white-coat" syndrome and forget to ask questions and be assertive. Prepare for your doctors appointments, including making a list of questions.
  5. Manage what you are putting into your body, caffeine, nicotine, food, as well as what you are doing with your body, like appropriate exercise and relaxation techniques. You can learn to reduce the pain by increasing the things that help: breathing techniques, pacing activities, applying heat or ice, stretching, moderate exercise, healthy diet, restful sleep, and decreasing the things that hurt: overly strenuous exercise, lifting, extended body position, caffeine and nicotine. If you're not sure which factors are instrumental, try keeping a pain log for a few weeks.
  6. The cognitive piece - People with chronic pain can find themselves developing a catastrophizing style of thinking. If you think this way, it becomes a self-fulfilling prophecy. You need to manage your thoughts that influence your pain experience.

What is your approach to a patient with back pain and what are the most important things all back pain patients should know? 

Brenda Hellmann, RNC/ NP, MSN:

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

As a Nurse Practitioner I am frequently the first provider seen for an initial assessment of back pain. My assessment includes onset of injury, symptom analysis, co-influencing factors such as lifestyle and previous injuries, and a self-care analysis. After the physical exam, I can order appropriate diagnostic tests, prescribe medication, refer to specialists, and do appropriate healthcare teaching.

Back pain usually doesn't develop at the time of an initial injury, but rather develops several hours later - after they've stopped doing the aggravating activity. Most back pain is worsened by associate muscle tightening and spasms. Early intervention with ice, non-steroidal anti-inflammatory medications, and stretching would promote quicker healing, as well as less pain and disability.

The most important things all back pain patients should know are:

  • Early self-intervention and treatment is very helpful.
  • Prevention through regular exercise and weight control is appropriate.
  • When it is appropriate to seek medical care.

What is your approach to a patient with back pain and what are the most important things all back pain patients should know? 

Joel Hellmann, MD:

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

As both an Occupational Medicine and Emergency Medicine specialist, I see back pain patients under different circumstances. As an Occupational Medicine specialist, I would be doing the primary care of back pain. Most people treating back pain, I expect, would use more or less the same initial patient history and intake evaluation and, unless there was a contraindication, would probably recommend similar initial treatments. My particular specialty has a work-place oriented perspective on back pain. In assessing, diagnosing, and providing rehabilitation recommendations to a patient, I need to consider the patient's work environment and the ways that the patient uses his/her back to perform in his/her job, and the potential risks that that job might pose for recurrent injury.

As an Emergency Medicine Specialist, I tend to see people who have just injured their backs, people who are in acute pain, or people who are unhappy with or have failed to respond to preliminary treatment prescribed by another healthcare provider. Emergency Physicians are available 24 hours a day in the Emergency Department for face-to-face emergent care. As an Emergency Physician I also have certain medications that can be administered intravenously and/or intramuscularly that other physicians may not have ready access to or may not be available in their office setting.

Different healthcare providers provide different services to patients with back pain. What gets offered is more often related to the secondary treatment of back pain - back pain that does not respond to initial conservative management or is more complicated than musculoskeletal pain such as that associated with evidence of neurological involvement. Where I might be able to provide services specific to Occupational or Emergency medicine, I would not be able to offer other treatments and services such as surgical intervention.

Here is what I think it is important for everyone with back pain to know:

  • They need patience with the healing process. Do it right the first time.
  • An understanding that an ounce of prevention is worth a pound of cure with respect to ongoing problems with their backs.
  • When to seek immediate care, the signs and symptoms that may indicate there is something more serious than a muscular problem.
  • How to perform basic and necessary activities of daily living such as getting into and out of bed, into and out of a car, sitting on and get up from a toilet, and other activities of personal hygiene without causing more discomfort or re-injuring themselves.