Ask The Doctor

We have a letter from a gentleman with low back pain. He has several issues he would like addressed.

Low back pain is very common and a primary care provider sees many of these patients in a month. Many of these might improve with manipulation by an osteopath or chiropractor but some do not. They must take medication and use exercises and stretches. I am an osteopath, or D.O., and we can and do all that an MD does, but we are also trained in manipulation of the joints to help our patients.

Physical therapy is also helpful with exercises and stretches tailored to your specific condition by a trained professional. Sometimes this doesn’t help.

ask_doctorMedication doesn’t fix the problem but allows the patient to move more to increase circulation and allow the body to heal itself. Our writer asks about salsalate as a medication. This is a good one but not proven to be better than ibuprofen which is also one of the large number of medications in the aspirin category. For pain there is also the narcotic category along with acetaminophen and tramadol. All four of these medication groups act on pain a different way. The aspirin group decreases inflammation but can also cause stomach irritation and bleeding or kidney injury in some people. Acetaminophen can cause liver failure if taken above the recommended dose.
Unfortunately, some patients do not improve with all of the measures outlined above and become chronic back pain sufferers. The pain-spasm-pain-spasm cycle keeps repeating and medical science has a hard time breaking it and chronic pain medications along with the stretches and exercises are the best way to manage it.

Our writer says he has facet dysfunction. As you are aware, the major weight-bearing joints of the back are between the backbones, or vertebrae, which have a disc as a pad between them. This arrangement is for weight bearing in an up and down direction. But for bending and twisting, there are projections off the vertebrae which join to other vertebrae to help and to limit movement. Your neck and lower back or lumbar spine can twist and bend quite a bit, but your upper back, or thoracic spine, cannot do much of these movements. Sometimes the joints between these projections, facet joints, are inflamed. The best way to diagnose these is to have an anesthesiologist inject an anti-inflammatory in the joint space as a treatment; if it works, then that is the diagnosis. There is no other test.

The writer tells us that he also has lost trust in his current provider and is about to see another. Trust is very important between a patient and a medical provider. Many studies have shown that without trust, the patient won’t tell the provider the proper information to come to the correct recommendation and will not take the medications or tests as prescribed. This leads to frustration on all sides. I’m glad the writer can seek other help, Some health care systems, such as those which are very remote or rural, or certain prison systems are unable to provide a choice for providers.

After trying the medications, exercises, stretches, physical therapy and many appointments, our writer states that he is not improved and wants my recommendation for therapy. It is very hard for us to recommend a plan without seeing the patient and the chart. I’m sorry I cannot be of more help other than what I have written here.

Prevention is the key to preventing years of pain. If you have an awkward or heavy object, ask for help. Use your legs (the largest muscles of the body) rather than your back. The large, long muscles of the back are up and down and help you some with this activity, but the small ones are for twisting and side-bending. If you don’t lift straight up and down, then you might overload the small muscles, causing a tearing, and then pain. So face your load, hold it tight to your chest, keep your rear end down and your head high, and use your legs to lift it up. Using a dolly or a hand truck also saves a lot of injuries.

Some use the girdles you see construction people wearing to protect the back. The studies I have read show that they do not prevent injuries much since the person using them may feel protected and lift a load improperly. In addition, the back becomes weak with these girdles and injuries can happen with light loads when the girdle is not worn.

As an aside, I was making hospital rounds, training my junior doctors and students, and visited a patient in the hospital recently who was admitted for chest pain. They were doing tests to make sure she wasn’t having a heart attack. After listening to her story, I suspected a rib out of place. I found it, and easily put it back in place and relieved her pain with one simple (osteopathic) move. There was no need for medication to be prescribed or for her to stay in the hospital.

Keep those letters coming!