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SKEPTOID BLOG:

Neck and Back Pain. The Top 10 Ways to Waste Your Money/Time.

by Stephen Propatier

May 22, 2013

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Donate Disclaimer: I commonly treat and diagnose spinal disease. Skeptoid is not a medical information page, its purpose is science education not medical treatment. This information is not a substitute for medical care and should be treated as informational only. Although I welcome comments and questions, I will not be able to answer specific questions related to any back or neck problems you may personally have. This would be a violation of US privacy laws and poor medical practice. So in advance, I am sorry.

Neck and Back pain estimates vary widely. Globally it affects about 330 million people as of 2010 (4.9% of the population). It is more common in women (5.7%) than men (3.9%). Nine out of ten adults experience back pain in their life. It is the fifth most common reason for doctor office visits. Total direct costs of neck-back pain-related health care utilization are estimated to be $86 billion a year. On average, health care expenditures for individuals with back pain have been estimated to be about 60% higher than those without.

I often tell patients that axial back and neck pain is multi-factoral. It has no single origin or treatment. If it was easily treated like a urinary tract infections there wouldn't be much interest in the use of nonscientific/unproven treatments. Here is a list of Ten popular misperceptions that drain your pocketbook/wallet, but do little to cure or reduce symptoms.

In no particular order:
  1. Bedding:The bedding industry has reams of advertising claiming superior sleeping for the spinal pain sufferer. Not true. The role of mattresses has not been studied in acute low back pain. The traditional teaching of recommending hard mattresses is called into question by a study in patients with chronic low back pain, which found better outcomes for medium-firm versus firm mattresses [78]. Responses to various mattresses are likely to be highly individualized. There is no evidence that any one sleeping surface is superior to any other. If you mattress is worn out replace for that reason. Otherwise save the money.

  2. Inversion or Traction devices. Expensive, they can cost thousands of dollars. Although people exposed to them can in fact feel better. There is no plausible way suspending yourself or "decompressing the spine manually" will reverse injury or degenerative changes in the spine. A systematic review identified 25 randomized trials of traction for low back pain, with or without sciatica. Only five trials were considered high quality, but the conclusion was that traction provides no significant benefit in short or long-term outcomes for low back pain patients with or without sciatica [74]. Inversion tables are expensive gadgets, good for the salesman, not good for the patients.

  3. Neck and Back Braces/corsets/belts. For the most part useless. Except in the setting of vertebral fractures and only when prescribed. There is evidence that soft collars prolong axial neck pain. There were two large studies showing that healthy persons wearing protective belts/braces were at higher risk of injury due to feeling overly secure about lifting. Randomized trials suggest little benefit from this preventive effort [75-77]. There is also little evidence to suggest that corsets or braces have therapeutic value for most patients [77].

  4. Massage therapy. Massage is good like all relaxation techniques it can be helpful in dealing with pain. However it is similar to Tylenol. Meaning it helps with symptoms. It does not treat the underlying problem. A few studies have evaluated massage and yoga for back pain treatment. The benefit of massage or yoga was found to be greatest in people with chronic back pain who expected to improve with one of these treatments [9]. So if you are hoping for a cure save your money.

  5. Yoga/Pilates. See above. Like all exercise I do recognize that Yoga/Pilates may be preventative for back and neck pain however I recommend that you avoid Yoga/Pilates while you are acutely in pain.

  6. Chiropractic/manipulation. See; http://skeptoid.com/episodes/4042.

  7. Acupuncture — Acupuncture and dry-needling have both been studied in low back pain, although predominantly for chronic symptoms. The techniques differ in that acupuncture points are typically determined by a traditional Chinese map linking specified points and lines (meridians) to physiologic variables and the flow of energy in the body. There are several schools and techniques. Dry-needling involves the use of needles (frequently acupuncture needles) inserted directly at points of myofascial pain to try to relievepain/tension at those points. Randomized trials of acupuncture and dry-needling tend to be small and heterogeneous in methodology, and blinding is difficult. Most available studies were reviewed in a 2005 systematic review that concluded that there is moderate evidence of short-term benefit to support the use of acupuncture in chronic low back pain [69]. Three acupuncture trials for acute low back pain were identified in this review; these studies found positive results, but the quality of the trials was too poor to draw definitive conclusions. My opinion expensive and useless.

  8. Prolotherapy (from "proliferant therapy"), or "sclerotherapy" in the osteopathic literature, is based on the theory that some back pain results from weakened or damaged ligaments. Injection with irritant solutions is believed to strengthen the ligaments and reduce pain and disability. The materials injected typically include some combination of dextrose, glycerin, phenol, and lidocaine. This is generally reserved for chronic back pain, and randomized trials do not support the efficacy of these injections in the absence of co-interventions [84].

  9. Opiate medications: Although effective for relieving pain, it is ineffective long term. Opiates are an easy answer and very attractive. There is no doubt opiates treat pain. There are major problems the longer you remain on them. In as little as 6 weeks you develop tolerance. In time it will become dependence. Pain is normal, disabling but normal. Your body will try to overcome pain blocking medicines by up-regulating opiate receptors. The more you are exposed to opiates the more your body becomes adept at metabolizing them. That is the trap. In time you develop opiate hyperalgesia. Your pain worsens due to synaptic up-regulation. Rapidly your liver adapts to metabolize the drugs quickly. Eventually you develop worse pain sensitivity due to the drugs. If you have chronic pain in a non-terminal condition, opiates will inevitably make your pain worse. Study's have shown that it eventually rewires your brain for increased pain. In my professional opinion and personal experience you are better off dealing with the pain now without the medicine. Otherwise you will have insurmountable pain in 2 years.

  10. Supplements/Foods/Herbs: the most popular are omega-3 supplements, glucosamine/chondroitin, co-enzyme Q. No evidence of efficacy, unknown side effects, and possible harm. Especially related to Glucosamine I reviewed this in an earlier blog.

Current Recommendation:

LOW BACK PAIN TREATMENT — Unless low back pain is caused by a serious medical condition, a rapid recovery is expected, even if there is a bulging or herniated disc. The body breaks down bulging discs, taking pressure off the nerve. Care of an attack of low back pain includes several simple elements. (See "Treatment of acute low back pain".)

Remaining active — Many people are afraid that they will hurt their back further or delay recovery by remaining active. However, remaining active is one of the best things you can do for your back. In fact, prolonged bed rest is not recommended. Studies have shown that people with low back pain recover faster when they remain active. Movement helps to relieve muscle spasms and prevents loss of muscle strength.

Although high-impact activities should be avoided, it is fine to continue doing regular day-to-day activities and light exercises, such as walking. If certain activities cause the back to hurt too much, it is fine to stop that activity and try another.

If back pain is severe, bedrest may be necessary for a short period of time, generally no more than one day [3]. When in bed, the most comfortable position may be to lie on the back with a pillow behind the knees and the head and shoulders elevated, or to lie on the side with the upper knee bent and a pillow between the knees.

Heat — Using a heating pad can help with low back pain during the first few weeks. It is not clear if cold packs help as well [4].

Work — Most experts recommend that people with low back pain continue to work so long as it is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. Some people need to stay home from work if their occupation does not allow them to sit or stand comfortably. While standing at work, stepping on a block of wood with one foot (and periodically alternating the foot on the block) may be helpful.

Pain medications — Take a pain medication such as aspirin, acetaminophen (Tylenol), or ibuprofen (eg, Advil) or naproxen (Aleve). Stronger pain medications, such as opioids, are reserved for people whose pain is not relieved with acetaminophen or NSAIDs.

If medication is needed, it is usually more effective to take a dose on a regular basis for three to five days, rather than using the medication only when the pain becomes unbearable. (See "Patient information: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

Muscle relaxants (eg, cyclobenzaprine, Flexeril) are available by prescription, but can cause drowsiness and are probably no better than ibuprofen in relieving pain [5]. Muscle relaxants may be helpful before bedtime when used for a short time. People who need to be alert, such as while driving or operating machinery, should not use muscle relaxants.

Exercise — Back exercises or stretching routines should not be used immediately after a new episode of low back pain because this could worsen or prolong pain. However, as symptoms begin to resolve, a program of exercises can help to increase back flexibility and strengthen the muscles that support the back [6].

Recommended activities include those that involve strengthening and stretching, such as walking, swimming, use of a stationary bicycle, and low-impact aerobics. Avoid activities that involve twisting, bending, are high impact, or that make the back hurt more. Some specific exercises may help strengthen the muscles of the lower back. People with frequent episodes of low back pain should continue these exercises indefinitely to prevent new episodes.

Physical therapy — If back pain has been present for more than 4 to 6 weeks, a healthcare provider may recommend working with a physical therapist to develop a formal exercise program. Exercise programs may involve stretching, flexion and extension exercises, strengthening, aerobic activity, general overall fitness, or some combination of these components. The physical therapist may directly supervise exercise sessions, or can teach the person to perform the exercise program at home.

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by Stephen Propatier

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