Back problems are the most common physical complaints in the United States and other developed countries. Although they can be caused by injury, many back problems are a result of lack of exercise, poor posture, use of vibratory tools, and psychological factors such as anxiety, depression, job dissatisfaction, and mental stress at work.

Acute low back pain is self-limiting, meaning that 90 percent of people recover in six weeks. But if recovery does not occur, chronic pain and disability are the primary results. In addition, if you have chronic low back pain, arthritis of the spine occurs much more quickly than otherwise and can be much more extensive than in normal aging. The spine can also become weaker, and this process can result in herniated (ruptured or slipped) discs, fractures, or spinal stenosis (narrowing of the spinal nerve outlets).

Common Symptoms

• Aching or stiffness anywhere along the lower spine
• Limited range of motion of the spine
• Pain after lifting, bending, or other activities
• Aching after prolonged sitting or standing
• Pain, numbness, or tingling down the arms or legs (radicular symptoms).
• Difficulty walking or climbing

What You Need to Know

Back braces are often prescribed for or used by people with low back pain. Although these braces can provide needed support and protection and lessen pain, they can also prolong healing and cause stiffness and loss of muscle tone. Use a back brace only when you need it for support, or when your doctor prescribes it for specific instability in your spine, or for prevention of further back injuries.

General Recommendations

Exercise: For acute back pain, formal exercises are often prescribed initially and can help some people, but they may make pain or inflammation worse for others. If your symptoms worsen with exercise, then postpone the exercises until symptoms decrease. Alternatively, I don’t advise complete rest because it may cause more stiffness, loss of muscular tone, and disability. Continue doing as many physical activities as you can tolerate, but don’t overdo them. Let your pain be your guide; some soreness is to be expected, but if you have severe pain, don’t continue the activity.

In chronic back pain, exercise is a mainstay of both prevention and treatment. Exercise stimulates large neurons (brain cells) to help reduce the perception of pain and stimulate the production of natural pain-killers from the brain. Exercises are recommended for all patients with chronic back pain. Stretching and resistance exercises are the main forms, along with exercises specifically designed for the back. However, because your back pain may be caused by different underlying problems, you should consult a physical therapist to help you design an exercise program for your particular condition.

Meditation: Regular meditation reduces stress and relaxes muscles and tendons of the back and neck. This reduces the severity and duration of symptoms.

Your Home Healing Action Plan for Recent Onset (Acute) Back Problems

• If you have severe and worsening back pain that extends down your leg, or paraysis, or inability to urinate or have a bowel movement, you may have a serious problem that requires emergency medical attention and diagnostic testing such as MRI or myelogram.
• There are several treatments for acute low back pain that I don’t recommend: traction, prescription antidepressants, lumbar supports, and TENS units (small devices that conduct electricity to the superficial soft tissues).

Step 1: Take Over-the-Counter Pain Relievers or NSAIDs

Your first step is to relieve your pain and decrease inflammation, thus allowing your body tissues to heal themselves. I recommend analgesics, such as Tylenol, or over-the-counter nonsteroidal anti-inflammatories (NSAIDs), such as Advil, Aleve, and ibuprofen.

Step 2: Take Prescription Medications to Relieve Pain and Inflammation or Relax Muscles

If the above drugs do not control your pain, your doctor can prescribe stronger nonsteroidal anti-inflammatory medications (such as Naprosyn, Feldene, Daypro, Orudis, Mobic, Cataflam, Relafen, Arthrotec, and many more). However, these drugs may cause stomach irritation and bleeding. If this occurs, you can try Cox-2 inhibitors, which have less risk of these side effects.

NOTE: Recent studies show an increased risk of heart attack in patients who use high-dose Cox-2 inhibitors along with naproxen (Aleve), so caution is advised. Also, if you have taken an NSAID (including ibuprofen) for a long time, it may precipitate a heart attack if you stop taking it suddenly. Obtain guidance from your doctor, especially if you have heart disease.

Muscle relaxants (such as Flexeril, Robaxin, Parafon Forte, Zanaflex, or Soma) are commonly prescribed and can reduce pain, but they cause drowsiness in many people. They are beneficial primarily in the first few days after an injury. Use prescribed narcotics for severe pain only a short period of time to avoid addiction, and avoid them altogether if possible.
The purpose of all these medications is to offer relief while healing is taking place, so you should take them only for a temporary period of time, until one (orseveral) of the following steps can work.

Step 3: Undergo Physical Therapy Modalities

Physical therapy modalities such as electrical current (applying low-voltage current to the area of pain), ultrasound (applying high-frequency sound that projects heat to the deep tissues), infrasound (low-frequency sound that increases local blood and lymph circulation and activity of the nervous system), hot/cold packs, and therapeutic massage can help accelerate the healing process. Use these treatments in combination for the best results. Ultrasound is sometimes helpful but can be irritating if there is inflammation.
These treatments can be provided by primary care doctors who have the necessary equipment, but if you are not improving, you should ask your doctor to refer you to a registered physical therapist. You should feel better after 6 to 12 treatments. If you don’t, proceed with the next step.

Step 4: Undergo Osteopathic Mobilization Therapy (OMT) or Chiropractic Manipulation

Osteopathic mobilization or chiropractic manipulation is helpful in uncomplicated back problems (that is, if you don’t have pre-existing back problems, such as severe arthritis, spinal stenosis, ruptured disc, or previous back surgeries), Manual therapy is helpful primarily if there are underlying structural problems (in other words, if bones, ligaments, tendons, joints, and/or muscles are not working correctly), which can be diagnosed via a chiropractic or osteopathic exam, If you have structural problems, then they must be corrected first, or your symptoms may recur, Your pain should start decreasing in 6 to 8 treatments, although additional treatments may be necessary to give you maximum benefit. If pain is still present after 10 to 12 treatments, structural problems are probably not the cause of your pain, and you may need further evaluation or a different method.

Step 5: Use Acupuncture

Acupuncture is effective for reducing pain, acute muscle spasms, and trigger points (small areas of muscle that become inflamed and are very painful when you push on them). In my clinic, we also have been able to relieve pain ftom bulging and herniated discs using acupuncture in combination with the low-energy laser. (Unfortunately, this laser is not yet readily available to most doctors, because it’s a research device. However, acupuncture alone may be effective for reducing symtoms enough to avoid surgery. Principal points are usually found on the back, behind the knee, and on the ankles. You should always seek evaluation and treatment from a practioner certified in acupuncture. You should feel better within six acupuncture treatments, but you might need additional sessions for maximum benefits.

Step 6: Undergo Diagnostic Testing to Discover More Severe Disc or Nerve Problems

If your back pain persists, leg symptoms worsen, or you develop urinary or bowel difficulties, you need diagnostic testing, such as MRI. This is the primary screening test uncovering abnormalities that are not present on a physical exam. This test requires to be placed in a narrow tube for 45 to 60 minutes, so, if you are claustrophobic, ask: doctor for Valium (10mg) to take before the test. There are also “open” MRI scanners available that do not cause claustrophobia.

Step 7: If the MRI Is Normal, Seek Counseling

If your pain continues despite normal test findings and continued treatment, underlying psychological factors may be occurring, even if you are not aware of them. Consider seeking an evaluation from a psychotherapist who treats pain symptoms. You should realize that when I advise you to do this, I am not suggesting that you are “crazy” or mentally ill. Many people simply do not realize that other psychosocial factors (such as job dissatisfaction, family problems, or financial difficulties) can prolong back pain, and once you are aware of these factors and how to deal with them, you can heal properly.

Step 8: If the MRI Is Abnonnal, Consider Epidural Steroid and Other Injections

If the previous steps have not helped you, then consider an epidural steroid injection (injection of cortisone into the lining of the spinal column). This procedure can relieve your symptoms if the MRI reveals disc or nerve abnormalities that correlate with the symptoms but do not yet require surgery-and if it has been less than two months since the start of your symptoms. If you get pain relief from the two initial injections, but it lasts only a few hours or days, further injections will usually not be beneficial, and I don’t recommend proceeding with more. If these injections are effective, pain relief should last four to six months and as long as a year. Epidural injections are not beneficial if you have normal test findings, and they are used primarily if leg pain is present.
Other injections can also be tried, depending on your symptoms, physical findings, and MRI results. These include trigger-point injections (injection of cortisone into “tender” muscle areas), facet-joint injections (injection of cortisone in the joint[s] connecting the bones of the spine), or selective nerve root blocks (injections of cortisone around the nerves coming from the spinal cord and going to the legs). Like epidurals, these injections are usually effective only temporarily, but they may allow time for the body to heal itself.

Step 9: Undergo Additional Diagnostic Testing

If your symptoms continue, I recommend further tests. One possibility is a discogram, which is the injection of a dye into the disc spaces. If leakage of dye is detected by X-ray­ and the injection causes the same pain that you have had shooting down your leg-you may have a disc rupture. Another test is the myelogram, in which dye is injected into the spinal column, outlining the spinal nerves as they leave the spinal cord and go to the leg. If the dye is seen to be obstructed, this may mean that the nerve is being compressed by a ruptured disc. Both of these tests can reveal abnormalities not observed on MRI, or they can confirm abnormalities that are seen on MRI.

Step 10: Consider Other Invasive Methods

Depending on what these further diagnostic tests show, there are other methods that can be useful for specific conditions. IDET (IntraDiscal ElectroThermal Therapy) is a procedure used when there is a tear in the covering of a spinal disc (an annular tear). IDET involves placing a wire around the disc and heating it, thus sealing the tear. lDET is most effective when you have only one or two damaged discs with a limited area of damage. Healing may take four to six months after the procedure, and physical activities must be severely restricted during this time. Long-term effectiveness is not known because IDET has been used only since 1997.

Step 11: Undergo Surgery as a Last Resort

Back surgery should be your treatment of last resort or when you have unrelenting leg pain or neurological signs (paralysis, or inability to urinate or have a bowel movement) that correlate with the results of the tests mentioned above. Surgery is often beneficial for reducing the pain that radiates into your legs, but it may not be as helpful for reducing the back pain. The optimum time for surgery is within three to six months of when the symptoms start, although beneficial results may still be achieved at longer intervals. In general, however, the longer the symptoms have been present, the poorer the results. In fact, surgery can sometimes predispose you to pain and other symptoms that become worse in the future, requiring additional back surgeries to relieve the additional symptoms.

Your Balanced Healing Action Plan for Chronic Back Pain

• Chronic back problems-those that last longer than three to six months-are very different from acute problems and do not usually respond to basic medications or physical therapy. Although stronger NSAIDs and other medications (such as the pain reliever Tramadol) can control the symptoms in many cases, I recommend proceeding with the following methods to eliminate the problems, which in turn can reduce or eliminate the need for medications.
  NOTE: Bed rest, biofeedback, long-term chiropractic manipulation, facet-joint injections, epidural steroid injections, lumbar supports, and traction have not been shown to be effective in improving chronic low back pain. At best, they may give temporary relief only, and I don’t recommend them.
• Many doctors may tell you that there is nothing more they can do to relieve your pain, and that you will just have to learn to live with it. I do not believe this is true for most people, especially if you use the following steps. Overall, the goal should be elimination of the pain, but complete relief may not be possible. A more reasonable goal is to lessen the pain enough to be able to enjoy life and be able to participate in most activities of daily living. In my experience, that goal can indeed be accomplished.

Step 1: Go to Back School

Sitting, lifting, and performing other activities properly are very important factors in both preventing and treating back problems. For example, many people with back problems also walk hunched over or sit stooped over a computer. They might lift without using their legs. I think that anyone with chronic back pain should attend a back school. These schools teach you dozens of ways to keep your back pain from worsening and flaring-up, and to avoid further injuries. Many registered physical therapists and rehabilitation specialists teach at back schools, so inquire in your area or ask your doctor for a recommendation.

Step 2: Receive Low-Level Energy Laser Therapy

I recommend the use of low-level energy lasers as the next step because, in my studies, the laser appears to help heal the tissue, reduce inflammation, and give long-lasting relief for arthritic, nerve, and disc problems. These lasers are called “cold” lasers because they do not produce heat like the hot lasers used in surgical procedures do. Their primary side effect (in about 25 percent of patients) is that they cause a temporary increase in soreness, which may last from one to three days. You should observe a decrease in symptoms within six to nine treatments. Because this is currently a research device unavailable to most doctors.

Step 3: Undergo Acupuncture

Acupuncture is very effective for chronic back problems. Principal points are usually found on the back, behind the knee, and on the ankles. You should always seek evaluation and treatment from a practitioner certified in acupuncture. You should notice improvement within six acupuncture treatments, but you might need additional sessions for maximum benefits. Occasional maintenance acupuncture may be necessary every 6 to 12 months.

Step 4: Undergo Osteopathic or Chiropractic Manipulation

Often, underlying structural problems (bones, ligaments, tendons, joints, and/or muscles not working correctly) are either causing your chronic back pain or not allowing proper healing to take place. I recommend osteopathic treatment to correct these underlymg structural problems. This first requires an osteopathic exam. If structural problems are evident, then they must be corrected before you get other treatments, or your symptoms may keep coming back. With osteopathic treatment, your pain should start decreasing in three to six treatments, although you might need additional treatments for maximum benefit. If your pain is still present after 10 to 12 treatments, further evaluation or a different method may be necessary.

Chiropractic manipulation can also be done and can help some people, but studies have not shown long-term effectiveness in most people. This is why I prefer osteopathic adjustments. If you choose chiropractic care, you should feel better within 6 to 8 treatments; occasional maintenance adjustments may be appropriate. I emphasize “occasional.” I see many patients who have received chiropractic adjustments every week (sometimes several times a week) for years, with pain relief lasting only a few hours or days. These perpetual, frequent adjustments are not appropriate and can be harmful. Do not continue with chiropractic manipulation after 10 to 12 treatments if you don’t get long-term relief.

Step 5: Try a TENS Unit

The previous steps are designed to reduce your symptoms for a long time. For continued pain that cannot be relieved long term, there are some treatments designed to give you temporary relief.

Start with a TENS unit (Transcutaneous Electrical Nerve Stimulator). You wear a small electrical generator strapped to your belt. The generator is attached by wires to small pads placed around the area of pain. Turning up the amplitude will give you more stimulation. You can wear one of these units continuously to control pain, although in some cases it can lose effectiveness over time.

Step 6: Apply Emu Oil, Long Crystal Menthol, Biofreeze, Capsaicin, Glucosamine/MSM, and Other Topical Solutions for Temporary Pain Relief

If you still have residual pain or flare-ups of pain, there are numerous topical solutions that can give temporary relief when you apply them over the painful area. These include emu oil, long crystal menthol, Biofreeze, capsaicin, and glucosamine/MSM, as well as other herbal combinations. These topicals are not curative, but they may provide pain relief for two to eight hours, and they have minimal side effects (the most common is ,skin allergy or sensitivity). Some of these may work better than others on different people, so you may have to try several to find the best one. In my clinic, I apply samples to my patients so they’ll know what works before they purchase it. Encourage your doctor or practitioner to do the same.

Other topicals use a mixture of prescription medications combined into a gel that is ansported into the soft tissues. Some of these medications include gabapentin (neurontin), ketoprofen, ketamine, clonidine, and amitriptyline (Elavil), but there are any others that can be helpful. A prescription from a doctor is required, but you can obtain the information from a pharmacist who mixes medications and bring it to your doctor for his approval.

Step 7: Take Prescription NSAIDs for Temporary Pain Relief

If the topical pain relievers are not helpful, then your doctor can prescribe stronger nonsteroidal anti-inflammatory medications (such as Naprosyn, Feldene, Daypro, Orudis, Jbic, Cataflam, Relafen, Arthrotec, and many more). These medications may take three weeks to be effective and should be discontinued if there is no benefit or the side effects (such as stomach irritation and bleeding) become intolerable. If this occurs, you can try Cox-2 inhibitors, which have less risk of these side effects.
NOTE: Recent studies show an increased risk of heart attack in patients who use high-dose Cox-2 inhibitors along with naproxen (Aleve), so caution is advised. Also, if you have taken an NSAID (including ibuprofen) for a long time, it may precipitate a heart attack if you stop taking it suddenly. Obtain guidance from your doctor, especially if you have heart disease.

Step 8: Take Appropriate Chinese Herbal Remedies

Several Chinese herbal formulations can reduce back pain and increase mobility, and you can safely take them with the previous steps. Formulas commonly used include Wan Du Hua Yu Tang, Shu ling Huo Xue Tang, or Huo Luo Xiao Ling Dan. Consult a practitioner qualified in Chinese herbal medicine to determine which Chinese herbal formulas are the best for your particular syndromes.

Step 9: Use Feldenkrais, Alexander, and Rolfing Forms of Bodywork

Bodywork involves realigning, rebalancing, and retraining the structures of the body that have become dysfunctional due to pain, injury, disuse, or misuse. Bodywork can be helpful for chronic back pain that doesn’t respond to other methods.

• The Feldenkrais method focuses on retraining the way you move your body; it interrupts unhealthy patterns of movement that have become habits.
• The Alexander technique concentrates on correcting faulty posture in daily activities (sitting, standing, and moving).
• Rolfing involves manipulating and stretching the body’s fascial tissues (deep connective tissues that hold your body together), allowing correct realigning of the body.

Each of these bodywork methods requires a certified therapist.

Step 10: Undergo Prolotherapy or Sclerotherapy

If the previous measures don’t relieve your pain, I recommend injections of natural substances to stimulate the growth of connective tissue to strengthen weak or damaged tendons and ligaments around the spine. In this technique, called reconstructive therapy, a mildly irritating solution (usually dextrose, glycerin, and phenol) is injected into the injured tissues, causing stimulation of the healing process. You should improve within six treatments and you’ll usually notice improvement during the first week.

Step 11: Practice Yoga Postures for Back and Neck

Yoga is often successful in reducing chronic back and neck symptoms. Yoga promotes relaxation and stretching, both of which are important in healing and preventing back pain. Because there are many different types of yoga, with some better for back pain than others, I recommend working with a qualified yoga instructor.

Step 12: Use Biomagnets

Biomagnets applied to the back (either taped or contained in a back brace) can reduce pain in some people. However, the relief lasts only while the magnet is in place.

Step 13: Practice Guided Imagery, Meditation, Biofeedback, and Hypnosis

Mind-body techniques such as guided imagery, meditation, biofeedback, or hypnosis may help when you use them along with the previous steps.

Step 14: Take Prescription Antidepressants

For some people, low-dose antidepressants, such as amitriptyline (Elavil) 25mg to 50mg daily, or trazodone (Desyrel) 50mg to 150mg daily, can decrease chronic back pain through effects on the pain center (hypothalamus) and neurotransmitters in the brain. However, they do not improve your ability to perform activities. You should try them if the previous steps are either ineffective or only partly effective in relieving your pain.

Step 15: Undergo Epidural Steroid Injections, Selective Nerve-Root Blocks, or Rhizotomy

If your pain is still present and is severe, you can try undergoing several types of spinal injections. Although very few people gain long-lasting relief from these procedures, they are worth a try before undergoing any surgery. Epidural steroid injections can occasionally benefit chronic back pain, but if two injections haven’t given you long-term relief, additional injections won’t either. Selective nerve root blocks can sometimes deaden a nerve, but again they may only give you temporary relief. Another procedure is called rhizotomy, in which your nerve root is destroyed by cutting it, using radio waves to destroy the nerve, or Injecting a chemical that destroys the nerve. This interrupts the pain message going to your brain. Often, however, your nerve will grow back and the pain will return. I would recommend rhizotomy only for intractable, unrelenting pain that prevents you from participating in most activities.

Step 16: Enter a Multidisciplinary Pain Program

If the previous steps are not beneficial, I recommend that you enter a multidisciplinary pain program. Although such programs are not designed to reduce back pain specifically, they do improve your ability to function and to go back to work, and they teach you to cope better with your pain.

Step 17: Undergo Surgery

Surgeries should be avoided if at all possible. Most surgeries done for chronic low back pain are fusions-your spinal bones (vertebra) are fused together using bone from your hip or with Instrumentation (rods, screws, and/or cages). Surgeries for chronic back pain should be done only for unrelenting pain with evidence of structural deterioration of the discs, and/or additional or worsening neurological signs. Surgery that involves a fusion at one or two levels exerts more pressure on the spinal disks above and below the fusion, typically causing them to deteriorate within two to five years. This is why many people have persistent or recurrent low back pain after these surgeries and end up undergoing many more surgeries.

Step 18: Take Prescription Narcotics

Narcotic pain-relief medications are appropriate only for severe, unrelenting back pain that has not responded to any other treatment approaches. These drugs vary in potency from tramadol or propoxyphene (the mildest) to OxyContin or morphine (the strongest). They are highly addictive. A physician specializing in pain management should monitor you when you are taking these drugs for chronic back pain.

Step 19: Use a Dorsal Column Stimulator

Placement of a dorsal column stimulator (DCS) into the spine can control chronic, severe spine pain, but it is effective in only about 10 to 20 percent of people and has a high failure rate over time, even among those who do receive relief initially. It is usually done only if back surgeries fail (a situation known as failed back syndrome, or FBS). DCS should be used as a last resort-only for continued severe back pain not helped by other treatments.

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