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Ending Back Pain: 5 Powerful Steps to Diagnose, Understand, and Treat Your Ailing Back Paperback – August 5, 2014
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About the Author
Jack Stern, M.D., Ph.D., is a board-certified neurosurgeon specializing in spinal surgery, and cofounder of Spine Options, one of America’s first facilities committed to nonsurgical care of back and neck pain. Dr. Stern is on the clinical faculty at Weill Cornell Medical College and has published numerous peer- and non peer– reviewed medical articles. He lives and practices in White Plains, New York.
Excerpt. © Reprinted by permission. All rights reserved.
I COULD CLAIM THAT IT was my wife’s fault. The year was 1990, and over the Labor Day weekend we’d traveled to Martha’s Vineyard to celebrate my birthday. Judy’s gift to me was a “special” massage that she’d thoughtfully scheduled, with the idea that it would help ease my chronic low back pain. But this wasn’t the usual massage rooted in the simple pleasures of Swedish wisdom. This was going to be an experience that had the masseuse gently walking all over my back. As I made myself comfortable on the cushioned table, I pictured a petite lady kneading my back muscles with her dainty feet. Instead, I met a rather robust, Teutonic-looking woman who proceeded to stomp across my back as I moaned and groaned in silence. I really didn’t want to appear wimpy, but I finally had to stop the massage because the pain had taken hold of me and began to sear down my leg. I soon learned that all the narcotics on the island did little to interrupt the connection between my brain and my back pain.
If I had to describe the pain, I’d say that it felt like electrical shocks shooting down my right leg. Though it came on gradually, over several hours, I reached a point where I couldn’t move or even find a comfortable position. I knew I was in trouble when the doctor in the ER offered to call the Steamship Authority and arrange for an emergency spot on the ferry to get me off the island. Luckily, we had taken our station wagon, so I had a reasonably comfortable ride home with the seat in the maximally reclined position. I never before appreciated Percocet and Valium so much!
Judy had called ahead to one of my colleagues, an anesthesiologist, who specialized in pain management so that by the time she dropped me off at the hospital, I had a team waiting to perform an MRI. Going by the images, they were prepared to perform a relatively quick and easy procedure. I had already diagnosed myself as having a disrupted lumbar facet joint, something you’ll read about shortly. This procedure involved what’s called a facet block, and I went home about an hour later, pain-free. I was fortunate to have such amazing access to proper medical care, and the knowledge to quickly figure out my problem. I know that millions of people are not as privileged when something goes so terribly wrong. This is in large part the reason why I wrote this book.
Without a doubt, that experience deepened my understanding of what many of my patients endure, and made me a more empathetic physician. It has allowed me to better understand their plight and have a profound appreciation for the mysterious and sometimes elusive nature of pain. It also has further empowered me to listen to and learn from them, for if I had to say what has influenced me the most throughout my career, it has been my patients. They have been my greatest teachers. Although we experience pain that is unique to each of us, there are patterns of pain—patterns that allow me to better understand the source of pain and enable me to venture a diagnosis and suggest a treatment plan based on how others with the same pattern found relief. In this respect, the diagnosis and treatment of back pain are no different from those for any other disease. They require a thorough history and physical exam; they also usually call for laboratory and/or imaging studies to confirm a diagnosis and identify a course of action that has been shown to be effective.
That said, what makes the treatment of back pain dramatically different from that of most other medical problems is of course the “pain” part. (For purposes of this book, “back pain,” unless otherwise specified, will refer to low back pain. Wherever necessary, I’ll refer to other types of back pain specifically.) My patients have also taught me that pain, especially if it goes undiagnosed or is improperly treated, frequently takes on psychological and social ramifications, all of which can change a person’s life forever. To treat these individuals demands a hefty dose of empathy and honesty—the patience to listen, the compassion to care, and the rectitude to admit failure when things go wrong. To treat these patients also demands the “art” of medicine that comes with time and experience. And on occasion, doctors like me find themselves in that wretched position of having to distinguish (as best we can) between a patient who needs medication and one who seeks it for the wrong reasons. I have to tell the difference between individuals who somehow benefit from the pain—a phenomenon that people usually don’t recognize in their own behavior—from those who don’t. So, in some regards, my job entails a mix of physiology, biology, and psychology. Frankly, that’s all part of what makes my job so intensely complex, challenging, and yet richly satisfying. In order for a physician like me to treat patients in pain, I need to look inward and examine all the moving parts aside from the pain.
A Method to the Madness
The statistics are sobering. Back pain is the second most common neurological ailment in the United States—only headaches are more common. And, after colds and influenza, it’s the second most common reason Americans see their doctors. At some point, almost all of us will have an episode of severe low back pain that will adversely interfere with our quality of life. It’s believed that low back pain costs the economy $50 billion to $100 billion annually. It’s the most common cause of job-related disability, accounts for more than 149 million lost workdays per year in the United States alone, and is the third most common reason for emergency room visits.
That’s a lot of sore backs. You’d think that if the vast majority of the population will experience back pain at some point, then there would be a national outcry for more relief. Despite remarkable advances and new and better ways to diagnose and treat back pain, the problem continues to grow at an alarming rate. Why? Back pain isn’t simple, and the solutions aren’t always straightforward. There is, however, hope. Looking at the problem as a person who both treats and has suffered from back pain, I believe I have an insight that others might not.
As a board-certified neurosurgeon specializing in spine neurosurgery and as cofounder of Spine Options, New York’s first and only center committed to nonsurgical care of back and neck pain, I’ve been on the front lines of the war on back pain for more than three decades and have treated more than 10,000 patients. My professional credentials are as a neurosurgeon, but I am acutely aware that surgery benefits only a select few. As such, my approach from start to finish is substantively different from those of most others in my field, and entails a multidisciplinary, holistic perspective that emphasizes the importance of a correct diagnosis prior to embarking on any treatment. In 1996, when I cofounded one of the nation’s first in-hospital holistic healing centers, I committed to the idea that people can get better without surgery or similarly invasive procedures. I am also a staunch advocate of the philosophy that “less is more.”
My motivation to write this book is simple: I’m alarmed by watching and reading all the misinformation about how to treat back pain. Every month in the United States alone, more than 4 million people Google the term back pain in hopes of finding information on why they hurt and what they can do about it. But what people find online is chaos—scattered information that’s confusing and inconsistent, and an overload of biased, self-serving advertising for various treatments. What’s more, back pain gets short shrift from both doctors and the general medical community, which is probably why chiropractors deliver about half of all back care in the country. And books or programs aimed to help back pain sufferers just don’t do the issue justice. Either they present back pain as an illegitimate, suspect medical issue or they espouse a particular treatment regimen and don’t address the multiple causes and potential remedies for back pain. Many spine-care professionals are familiar with just a limited menu of options and are unable to provide sound advice across the entire field. This has the unfortunate effect of leaving patients confused about which course to take.
In 2013, the topic hit headlines when a new study out of Harvard Medical School revealed that the number of people who have been prescribed powerful painkillers or referred for surgery and other specialty care have increased in recent years—despite guidelines to treat back pain conservatively. “Conservative management” in most cases means using aspirin or acetaminophen (Tylenol) and physical therapy during a wait-and-see approach rather than going directly to advanced imaging procedures, narcotics, and referral to specialists. In the study published in JAMA Internal Medicine, researchers looked at 23,918 outpatient visits for back pain, which was intended to reflect a sample of an estimated 440 million visits made over twelve years in the United States. After factoring out certain variables such as age, gender, and the nature of the pain, they found that during this time, over-the-counter, non-steroidal anti-inflammatory drug use (e.g., Aleve and Tylenol) fell 50 percent, while use of prescription opiates increased by 51 percent and CT or MRI scan tests rose by 57 percent. Meanwhile, referrals to other doctors climbed by 106 percent; the authors of the study pointed out that this likely contributed to the surge in expensive and often unnecessary spine surgeries.
This is alarming, to say the least. Although there is a time and place for painkillers and surgery, as this book will explain, few people are aware that there are safer, much more effective alternatives that can ease or eradicate back pain. Some of the strongest evidence, for instance, actually supports treating pain with exercise for certain types of back pain. And some 95 percent of people will recover from back pain without invasive or risky treatments. I find it telling that a 2012 Japanese study revealed that when adults suffering from chronic back pain visited an amusement park, they reported that their pain decreased significantly. But it came back once the trip was over. So much about back pain can be rooted in one’s psyche and mind, a hotly contested subject matter that will be covered in this book.
Given the fact that most people will develop an aching back at some point, it shouldn’t be viewed as an abnormal condition that necessitates costly medical care. We can probably change the entire back pain industry by just seeing it in a different light. Rather than approaching back pain as if it were an illness or disease, we should acknowledge it as a normal, inevitable aspect to aging that is for the most part ideally managed through patience and a change in lifestyle. Although most of us prefer quick fixes, sometimes the best advice is to wait and see.
Simon Dagenais, D.C., Ph.D., a prolific researcher who conducts studies to support evidence-based management of spinal and orthopedic disorders, articulated it perfectly when he said that choosing a treatment for back pain is akin to “shopping in a foreign supermarket with illegible product labels when one is hungry.” Indeed, there are hundreds if not thousands of possible treatments for back pain, plus dozens of diagnostic approaches. The question is, though, how does the average person navigate all the options and know which is best? And how can a patient learn to be an advocate for his or her health without worrying about being a difficult patient? This book will help you answer these perplexing questions to get the back pain relief you need that is most appropriate for your condition.
A Little History
Lower back pain has afflicted humans for as long as we’ve roamed the planet. It’s an experience nearly as universal as the common cold. In 2003, Drs. Guido R. Zanni and Jeannette Y. Wick wrote a marvelous, well-documented piece for the Journal of the American Pharmacists Association titled “Low Back Pain: Eliminating Myths and Elucidating Realities.” In it, they chronicle the history of back pain from ancient times to the modern era, describing early evidence dating back to an Egyptian papyrus from 1500 BC that may be the first written clinical description, and suggests the treatment of lying down. Biblical references to back pain include the famous one in Genesis in which Jacob is suffering from sciatica after he struggles with an angel. During the Middle Ages, people turned to folk medicine for help with their pain because they believed that supernatural causes created such discomfort.
Formal writings on back pain didn’t really emerge until the 1800s, when physicians finally began to connect back pain with trauma or injury. Up to that point in time, most doctors believed the pain was a form of rheumatism or lumbago, which refers to pain in the muscles and joints. But even then, as today, visible pathology didn’t necessarily translate to predictable symptoms that made sense. One can have clear evidence of damage on an imaging test, for instance, but have absolutely no pain—or vice versa, whereby there’s pain but no obvious source for the pain seen on an X-ray, CT scan, or MRI, or with other imaging technology.
Although doctors didn’t have a handle on back pain throughout much of history, surgery to alleviate the pain has long been among the most common, and most invasive, of medical procedures. One can only imagine the kind of primitive forms of medical treatments that were applied to back pain patients who were desperate to end their misery. In the fifteenth century, the surgeon Şerefeddin Sabuncuoğlu detailed lower back pain in handwritten manuscripts with illustrations. His recommendations for treatment included the use of analgesic medications and, when warranted, a cauterization (burning) procedure.
Dr. Sabuncuoğlu was right to prescribe analgesics to help back pain originating from trauma or injury. Even his surgical interventions may have been helpful for stubborn pain if he managed to hit the exact area from where the problem emanated. After all, how different is this from the common practice of trigger-point injections, a type of pain treatment by which areas of muscular pain are injected with anesthetics and steroids to alleviate the pain? Modern options for treating back pain go back hundreds of years as well. Today’s inversion tables and matted platforms consisting of pulleys, ropes, and weights to relieve back pain are reminiscent of contraptions from the Middle Ages. By some standards, they may look like tools for torture.
Zanni and Wick relate the events of the early twentieth century beautifully: “. . . as societies struggled to develop social systems to address worker disability, physicians and politicians debated the reality of back pain. Some called it a ‘litigation symptom,’ and eminent psychiatrists of the day, including Sigmund Freud and Pierre Janet, went so far as to label back pain as a pathologic manifestation of unconscious conflict. Back pain gained a reputation as an emotional, rather than real, affliction.”
It was during this time period that health statisticians began tracking the incidence of lower back pain. By the 1950s, other areas of medicine, chiefly those that were revolutionized by antibiotics and insulin, grew by leaps and bounds. Vaccines changed the course of ailments such as polio and smallpox, and improvements in people’s general lifestyle (i.e., diet and exercise) helped prolong our lives further, allowing us to live well into our seventies and eighties. But when it came to back pain, the pain persisted. What’s more, an increasing number of workers’ compensation claims brought back pain to the forefront of analysis.
Although it’s now generally acknowledged that lower back pain is a serious and real medical problem, many people still choose to believe and give credence to biases of malingering. It’s often considered a workers’ compensation nightmare because costs of back pain claims are exorbitant, and it’s undeniable that some workers do exploit or abuse the system. Experience, however, has shown me that few individuals are wildly exaggerating or faking their pain. In some patients there are disconnects between their symptoms and the findings on physical examinations and imaging studies. In other words, someone whose symptoms don’t match a valid diagnosis or pathology is often suspected of “symptom magnification.” I also believe that almost all patients who demonstrate this disconnect are unaware of their behavior, a phenomenon I’ll explore.
With this book I hope to present a new paradigm for the diagnosis and treatment of back pain. You may not find your personal solution on the very first page (or maybe you will), but my goal in this book is to equip every back pain sufferer with the information and power to get to the bottom of his or her own problem. In a world of rapidly changing technology, competing information, and an increasingly troubled health care industry, it may seem impossible to know what you need and, more important, how to get it. Ending Back Pain is your step-by-step companion to sleuthing your way to a more pain-free existence. Indeed, after centuries of searching for answers to this most common ailment, the time has come to put an end to the misery. As I hope to show in this book, the power to end back pain is within all of us.
PERHAPS YOU’RE READING THIS while trying your best to avoid the next unbearable sensation of pain in your back. Maybe you’ve been dealing with back pain for a long time and are fed up with the ongoing, endless struggle for which you don’t have a clear diagnosis or solution (or the original diagnosis and treatment didn’t bring total relief). Or perhaps you’re someone who has just begun to experience back pain and you’re terrified that it will get worse over time, especially since your doctor has as yet been unable to pinpoint a real cause, much less a suggested cure. You don’t know where else to turn, and you keep asking, Why me? Will this come to define the rest of my life? What should I do now? How can I end the pain and prevent this from happening again? The fear of living with chronic back pain looms large.
Regardless of your unique story and circumstances, I’m here to help you discover how to take charge of your back pain, and carry you to a place where you can live the most pain-free life possible. In five steps, you’ll learn how to:
• Unlock your back’s unique code through an appreciation of the six major anatomical sites that can cause low back pain, which are called the pain generators, as well as non-anatomical causes of low back pain, such as drugs and underlying medical conditions or diseases. Put simply, Step 1 gives you a clear road map to use for getting to the bottom of your back pain’s origins.
• Be an advocate for yourself with health professionals. Step 2 supplies you with all the instructions and self-evaluations you need to then approach a doctor and optimize that relationship.
• Ensure proper diagnosis. In Step 3, you’ll learn in detail the whys and hows of pain emanating from the back’s main pain generators, which will ultimately help you to get diagnosed correctly. You’ll also get inside my head as I share what a doctor like me thinks when someone with your type of pain enters my office. Between the lessons learned and questionnaires you complete in Step 1, you’ll have a much better idea about which type of pain is relevant to you so that you can make the most of Step 3.
• Embark on a plan of treatment and recovery based on your individual diagnosis, one that will entail a wide variety of options from least to most invasive. Step 4 reveals all the common approaches to back pain as well as offers a candid look at what happens when nothing seems to work—when the pain may actually come more from the mind than the back. Some of the solutions described in this step reiterate the treatments explained in Step 3, but the goal is the same: to help you make the most of your journey to a pain-free back, whether that involves an integration of therapies or a single remedy.
• Take advantage of strategies to prevent future back pain and live as much a pain-free life as possible. Finally, Step 5 showcases the strategies for ending back pain for life—offering my hope that future back pain treatment will improve and that there is a lot we all can do today to prevent back pain in the future. In the conclusion, I’ll help you see how all five steps come together, stressing once again that the cure for back pain is rarely a magic bullet. It’s an ongoing plan of action.
Although I’ve created a five-step program, this book does things a little differently. You’ll find that there will be lots of crossover among the steps; this subject matter requires us to touch upon many of these steps at the same time. The information about being your own advocate in front of health professionals, for example, will relate directly to both understanding your unique pain and getting the right diagnosis. Similarly, your path to a pain-free back will demand that you respect your emotions and psychological circumstances while you consider specific anatomical problems that play into your back pain. In other words, healing your back pain involves an amalgamation of all five steps. I have organized this book to maximize your journey through these steps. And I’m going to start you off with a quick questionnaire, which will help you start gathering the clues you need to understand your own back, before leaping into Step 1.
Due to the volume of material covered, and to further help you to know exactly what to do, I’ve created itemized action plans wherever appropriate at the ends of certain chapters. They serve to both highlight key points and give you specific action steps to take, based on the information in that chapter. Some of these action steps may not be relevant to you, but you’ll know how to distinguish between what’s applicable to your type of pain and what’s not. Virtually nothing about back pain is one-size-fits-all, so I’ve written this book to be user-friendly and adaptable to you, no matter what kind of back pain you’re dealing with.
Of all the advice dispensed on alleviating low back pain, two overwhelmingly critical issues are frequently neglected. I will hammer these issues consistently throughout the book. One is diagnosis. Ending back pain requires an accurate diagnosis, which many people do not receive. There are many reasons for this, and we’ll be exploring how you can avoid this fate. And two, back pain is one of those few ailments that are manifested across a wild spectrum of the population. Put another way, no two back pain patients are exactly the same. Unfortunately, when most back pain patients talk to their doctors, the complaints fall on inattentive ears. Doctors hear about back pain so frequently that they’ve become desensitized to the problem, and in addition they know that most back pain resolves spontaneously without any interventions. As a result, they don’t spend a lot of time thinking through solutions tailored to each patient’s individual case. They typically offer a single remedy to all patients, which may not be the right one.
So, what happens when you have unresolved, persistent back pain? You are, quite honestly, a big problem for your doctor. How do I know this? Because that’s how I felt before I began to think more critically about unrelenting back pain. Most physicians, when asked, won’t hide their frustration about the prospect of dealing with back pain. It’s a time-consuming, multifactorial quandary, which the average physician is not adequately trained to treat. It’s the reason a whole new specialty of medicine was created in the 1990s, called pain management, and one I find myself practicing daily as a back pain doctor.
Before We Get Started
So, we begin our journey here with a few commitments that I ask you to make. By using this book, you are resolving to be your own advocate for getting the right diagnosis and care. I’ll be sharing with you the knowledge you need to do this, but learning the information is only half the battle. You have to execute the lessons here. At the same time, open yourself up to understanding the main causes of back pain and the wealth of treatments available. I realize that some of you may think that as an active surgeon I will push surgical options. Far from it! The repertoire of potential treatments runs the gamut of choices, from traditional Western medicine to Eastern medicine to chiropractic and to integrative therapies such as Pilates and the Alexander Technique, to name a few. And if surgery is the ultimate recommendation, then this book will help you make that decision and be well informed about the pros and cons.
By and large, Ending Back Pain is intended to be the practical, hands-on guide that will help anyone with back pain find a more pain-free life—whatever that entails. For some of you, a “cure” could be having a totally pain-free back in just a few weeks using a certain protocol, or maybe it will mean that you feel better in a month and are able to function more easily at home or work but will still have some pain to manage. I know all too well that back pain tends to have more than one trigger, more than one source of agony. Your pain may not be caused by a well-defined diagnosis, such as a slipped disc. In fact, more frequently than not, the pain is rooted in a constellation of physical mishaps made all the more vexing by emotional, psychological underpinnings.
This is precisely why my “whole patient” approach to healing goes far beyond simply treating an ailing back. It’s designed to get to the root of the problem of low back pain, even when the solution involves learning to live with some of the pain. Please use this book however you want to make the most of its information. As you read, highlight or circle anything about pain that seems relevant to you. Write in the margins or keep a journal to take notes and complete the exercises I’ll be giving. To access the most up-to-date information and online tools that will help you take full advantage of the recommendations in this book, go to www.drjackstern.com. There, you’ll be able to stay on top of the latest in back pain studies, learn about the most recent technologies that may be relevant to you, and view my ongoing blog and video content where I share what’s going on in the back pain community.
By the end of this book, my hope is that you’ll have gathered your own set of “symptoms,” which is the first step to a diagnosis. I should point out that this book is not just for people who suffer from back pain, but it’s also for your loved ones, who can help in the healing process. In addition to presenting the requisite “how to diagnose and treat” back pain, we’re also going to explore some of the lesser-known facts related to the subject. For example, why is back pain practically nonexistent among certain populations? How much does the psychology of pain play into the biology of pain? And why will some patients never become pain-free regardless of proven solutions available to them? These questions, and so many more, will be answered. My ultimate goal is to inform and, of course, empower you to end your struggle with back pain. Back pain is not the enemy; our current way of addressing it is. It’s time that you take control . . . and get your life back.
Unlock Your Back’s Unique Pain Code
If I had to sum up this entire book in a single phrase, it would be this: Get to know your back. Ending back pain begins with you. One fact I’ll be repeating over and over again is that diagnosing back pain is a tricky combination of art and science. Indeed, lots of high-tech tools are available to us in medicine, but that doesn’t mean that diagnosing, let alone curing, back pain is a black-and-white endeavor. Unfortunately, it’s very much to the contrary—complex, imprecise, and immensely vexing. So, the more you can contribute to the story of your back pain, the more you can shift your experience to one that’s less reliant on art and more based on science.
As a prelude to Step 1, which will equip you with the information you need to decode your own unique pain, use the following checklist to organize your thoughts and personal information. This questionnaire is designed to help you prepare for a doctor’s visit, giving you clues to what to discuss. But it should be filled out even before reading this book, because it will help you get to know yourself and your particular back pain better before embarking on this adventure. I also know that you want to be told what to do as soon as possible, and even though you’ll find much to consider throughout this book, the following questions will provide you with concepts to think about as you read further and apply my ideas to your life. Your answers will help you get the most out of this book, and find a solution sooner rather than later.
Check off as many of the following questions that apply to you and bring this checklist with you to your doctor. Add additional notes where necessary. This questionnaire is also downloadable online at www.drjackstern.com, where you’ll find a version that you can fill out directly on the page, print for your records, and/or take to your doctor.
How long have you been experiencing back pain?
• within the past six weeks
• for more than six weeks
Do you have a personal or family history of any of the following:
• degenerative disc disease
• osteopenia or osteoporosis
• rheumatoid arthritis
• psoriatic arthritis
• urinary tract (bladder) infections
• kidney stones, urinary tract or kidney infections, or kidney disease
• any type of cancer (if so, which kind?)
Does your pain get worse by any of the following:
• engaging in a sport
• doing a certain activity
• sitting for a long period
• Is your pain relieved by rest?
• Is your pain relieved by non-steroidal anti-inflammatory drugs, such as Aleve (naproxen) and Advil (ibuprofen)?
• Does your pain radiate downward and stop somewhere? Where does it start? Where does it stop?
• Is your pain one-sided (on one side of your back or down one side of your leg)?
• Is the pain accompanied by a fever or weight loss?
• Does the pain occur when you stand, stretch, or sit?
• Is your pain worse in the morning and better at night?
• Is your pain better in the morning and more pronounced with activity?
• Does it intensify if you cough, sneeze, or move your bowels?
• Have you been injured or been in a recent accident?
• Have you recently participated in an activity or sport that you haven’t performed in a long time (e.g., painting the house, raking leaves, playing dodgeball, exercising, skiing)?
• Do you have any soreness specific to a single muscle area, such as your hamstrings or quadriceps?
• Do you smoke?
• Are you overweight?
• Are you over the age of fifty-five?
• Do you have weakness in one leg that causes you to drag your foot?
• Do you experience tingling (a “pins and needles” sensation) or numbness in one arm?
• Do you have to turn your entire body to look over to the right or left?
• Do you feel pain in other areas, such as your shoulders, mid-back, buttocks, or thighs (but not below the knee)?
• Is it hard to stand up straight and get up out of a chair?
• Do you play tennis or golf?
• Was the onset of pain sudden and upon performing a specific act, such as bending to pick something up off the floor or reaching for a heavy box on a shelf?
How would you describe your pain?
• Does your pain serve you in any way? Are you addicted to your pain? Have you thought about what life would be like without the pain?
WHERE IS YOUR PAIN AND HOW DOES IT BEHAVE?
Draw your pain in the below figure. It can be a dot, a jagged line, a shaded section, and so on. If your pain travels from your back to somewhere in your front, make note of that in the margin and be as specific as you can. If you have a combination of issues, such as searing pain in one area and numbness in another, indicate that by using X’s for the searing pain and Y’s for the numbness. If the pain has changed over time, use more than one avatar and try to label it according to when the change occurred and if you know why.
Unlike other self-tests you may find in books and magazines, this one doesn’t have a scorecard at the end. Your answers are your own. If you’re like most people, you may not even know what some of your answers mean, or exactly what to do with them. And that’s okay. By the end of this book you’ll know precisely how your responses will play into diagnosing and treating your pain. Once you’ve read further, and perhaps after applying some of my forthcoming suggestions, come back to this questionnaire to check in with yourself whenever you want. Or return to it when you think you can provide more comprehensive answers. If you weren’t able to respond to one or more of the questions, you might be better equipped to do so once you’ve made more headway through the book. Mind you, there will be lots of opportunities to document your experience, as this book provides several self-tests and evaluations. But use this first checklist as your “cheat sheet”—your summary of main points related to your pain. Your responses could eventually turn into a game plan from which all treatment and preventive measures commence.
Where is your pain and how does it behave?
The Science and Art of Diagnosing Back Pain
MOST FEELINGS OF DISCOMFORT in life have clear solutions. For a stuffy nose, decongestants do the trick. For a pounding headache, aspirin or Tylenol comes in handy. But what do you do about a relentlessly aching back? As most of us know, the answer is not nearly as clear-cut as we’d wish. And unlike infectious diseases that often have targeted remedies (think antibiotics for bacterial infections and vaccines for viruses), ailing backs are like misbehaving, obnoxious family members—we can’t easily get rid of them or “fix” them. They also have a tendency to stick around and bother us nonstop, lowering our quality of life considerably and indefinitely.
Perhaps nothing could be more frustrating than a sore or hurting back. It seems to throw off everything else in our body, and makes daily living downright miserable. With the lifetime prevalence approaching 100 percent, virtually all of us have been or will be affected by low back pain at some point. Luckily, most of us recover from a bout of back pain within a few weeks and don’t experience another episode. But for some of us, the back gives us chronic problems. As many as 40 percent of people have a recurrence of back pain within six months.
At any given time, an astounding 15 to 30 percent of adults are experiencing back pain, and up to 80 percent of sufferers eventually seek medical attention. Sedentary people between the ages of forty-five and sixty are affected most, although I should point out that for people younger than forty-five, lower back pain is the most common cause for limiting one’s activities. And here’s the most frustrating fact of all: A specific diagnosis is often elusive; in many cases it’s not possible to give a precise diagnosis, despite advanced imaging studies. In other words, we doctors cannot point to a specific place in your back’s anatomy and say something along the lines of, “That’s exactly where the problem is, and here’s how we’ll fix it.” This is why the field of back pain has shifted from one in which we look solely for biomechanical approaches to treatment to one where we have to consider patients’ attitudes and beliefs. We have to look at a dizzying array of factors, because back pain is best understood through multiple lenses, including biology, psychology, and even sociology.
WHAT ARE THE CHANCES?
Chances are good that you’ll experience back pain at some point in your life. Your lifetime risk is arguably close to 100 percent. And unfortunately, recurrence rates are appreciable. The chance of it recurring within one year of a first episode is estimated to be between 20 and 44 percent; within ten years, 80 percent of sufferers report back pain again. Lifetime recurrence is estimated to be 85 percent. Hence, the goal should be to alleviate symptoms and prevent future episodes.
So, why is back pain such a confounding problem? For one, it’s lumped into one giant category, even though it entails a constellation of potential culprits. You may have back pain stemming from a skiing accident, whereas your neighbor experiences back pain as the consequence of an osteoporotic fracture. Clearly, the two types of back pain are different, yet we call them “back pain” on both accounts, regardless. Back pain has an indeterminate range of possible causes, and therefore multiple solutions and treatment options. There is no one-size-fits-all answer to this malady. That is why diagnosing back pain, particularly persistent or recurrent pain, is so challenging for physicians.
Some people are able to describe the exact moment or series of moments when they incurred the damage to their back—a car accident, a slip and fall, a difficult pregnancy, a heavy-lifting job at work, a sports-related injury, a marathon, and so on. But for many, the moment isn’t so obvious, or what they think is causing them the back pain is far from accurate.
Before we begin to address your unique back pain, it helps to start with a grasp of the two main types of back pain and the three general types of patients.
The Two Types of Back Pain
If you are going to experience back pain, you’d prefer to have the acute and temporary kind rather than the chronic and enigmatic kind. The former is typically caused by a musculoskeletal issue that resolves itself in due time. This would be like pulling a muscle in your back during a climb up a steep hill on your bicycle or sustaining an injury when you fall from the stepladder in the garage. You feel pain for a few weeks and then it’s silenced, hence the term self-limiting back pain. It strikes, you give it some time, it heals, and it’s gone.
The second type of back pain, though, is often worse, because it’s not easily attributed to a single event or accident. Often, either sufferers don’t know what precipitated the attack, or they remember some small thing as the cause, such as bending from the waist to lift an object instead of squatting down (i.e., lifting with the legs) or stepping off a curb too abruptly. It can start out of nowhere and nag you endlessly. It can build slowly over time but lack a clear beginning. Your doctor scratches his head, trying to diagnose the source of the problem, and as a result your treatment options aren’t always aligned with the root cause of the problem well enough to solve it forever. It should come as no surprise, then, that those with no definitive diagnosis reflect the most troubling cases for patients and doctors.
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