Back Pain

Some people have back pain that does not go away. Back pain is considered chronic when it lasts longer than six months. Chronic low back pain affects about 10% of the population.⁴ It is one of the most common reasons for disability. Additionally, among all health conditions, back pain is one of the highest costs to the healthcare system.^{5, 6} 

Despite these alarming statistics, it is important to recognize that most people with chronic back pain live well and do not seek healthcare for it on a regular basis. Roughly, three quarters of people with chronic back pain fit this description.⁷ They are neither distressed nor impaired enough to seek care for it. Or, they recognize that medical options for chronic back pain are limited and not very effective. So, they self-manage their chronic back pain. Either way, it is possible to self-manage chronic back pain and live well enough to have no need to seek care for it. In fact, the majority of people with chronic back pain are not seeking care for it.

Common causes of back pain are varied. Broadly speaking, the many common causes of back pain can be divided into three categories: muscular, orthopedic, and nervous. Muscle strain and tears can cause back pain. Degenerative changes of the spine are commonly thought to cause pain. Changes in the nervous system, commonly referred to as central sensitization, can also cause pain. Less common causes of back pain are spinal fractures, infection and cancer.

It is often difficult to know the cause of back pain in an individual case. There are no examinations or tests that can definitively prove a cause of pain for any of the three most common categories of causes mentioned above.

Take, for example, orthopedic causes of back pain. CT or MRI scans are commonly used to identify degenerative changes of the spine as possible causes of back pain. When found, it is easy to assume that these findings provide a definitive diagnosis of the cause. However, most healthcare providers know that the research does not support this assumption.

To understand this point, it is helpful to know something about how science goes about finding a cause of pain in general. In order to find a cause of pain, scientific inquiry tries to find something that is unique to those who have pain and which subsequently differentiates those who have pain from those who do not have pain. Findings of degenerative changes of the spine on MRI or CT scans are not unique to patients with back pain in this way. Numerous studies consistently show that people without back pain have degenerative changes of the spine at just as high a rate or higher than people with back pain.^{8, 9, 10} There currently is no way of knowing what differentiates degenerative changes of the spine that are painful from those that are not painful. Another possibility is that there is no difference and the findings of degenerative changes of the spine on MRI or CT scans are simply irrelevant. There is currently no test that can tell for certain.

As such, in the individual case, it is difficult to know what is causing pain, even if an MRI or CT scan shows degenerative changes of the spine. Are these changes relevant to the patient’s pain when we know that people without back pain are likely to have the same findings? Healthcare providers don’t ultimately know.

Is there a cure for chronic back pain?

In the absence of a known cause, healthcare providers and their patients often proceed through various therapies and procedures on a trial-and-error basis. There are many common treatments for chronic back pain:

• Anti-inflammatory medications
• Muscle relaxant medications
• Antidepressant medications (used for pain)
• Anticonvulsant medications (used for pain)
• Opioid, or narcotic, medications
• Chiropractic care
• Physical therapy
• Cognitive behavioral therapy
• Epidural steroid injections
• Rhizotomy
• Back surgeries – laminectomies, disctectomies, and fusions
• Implantable pain control devices – spinal cord stimulators and intrathecal drug delivery devices (aka, “pain pumps”)
• Chronic pain rehabilitation programs

Many of these therapies and procedures have been shown in research to be effective in reducing pain and increasing functioning. However, in this regard, effective does not mean curative. Unfortunately, there are no known cures for chronic back pain.

Therapies & procedures for chronic back pain

In 2007, the American College of Physicians and the American Pain Society developed clinical practice guidelines for chronic back pain.¹¹ They determined that providers should first recommend self-management for patients with back pain. Moreover, they recommended that healthcare providers educate patients on how to self-manage back pain. They do not recommend the use of immediate CT or MRI scans for back pain unless there is evidence of severe neurological problems or evidence of other severe conditions like cancer or infection. If back pain continues and becomes chronic, they recommend the use of medications and chronic pain rehabilitation therapies.

In terms of medications, they note that even the most effective medications only moderately reduce pain. They recommend the use of acetaminophen and non-steroidal anti-inflammatory medications first. If these fail to reduce pain, they recommend using tricyclic antidepressant medications. They note that these three classes of medications have the most and highest quality evidence supporting their effectiveness. They also note that the poor quality of evidence for the use of opioid and anticonvulsant medications.¹² 

In terms of chronic pain rehabilitation therapies, they recommend the use of exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs (which put the two previous types of therapies together in a coordinated fashion).

The clinical practice guidelines recommend MRI or CT scans and possible referral for surgical evaluation only if patients meet two criteria: a) when patients fail to progress from the above-mentioned treatments and b) they show evidence of neurological problems, such as referred pain.

It is important to recognize that the order of these recommendations reflect the likelihood of their being effective. That is to say, based on the available research evidence, the first recommendation is the one that is most likely to be helpful, the second recommendation is the second most likely to be helpful, the third is the third most likely to be helpful, and so on.

It is also important to recognize how often these guidelines do not get followed in actual practice.¹³ While many patients have acetaminophen and non-steroidal anti-inflammatory medications recommended to them, most patients do not get tricyclic antidepressant medications, exercise, cognitive behavioral therapy, or chronic pain rehabilitation programs recommended to them. When they do, it is only after they have undergone MRI or CT scans and have tried multiple interventional and surgical procedures, all of which have either poor quality research supporting their effectiveness or are known to be less effective.

References

1. Deyo, R. A., Mirza, S. K., & Martin, B. I. (2006). Back pain prevalence and visit rates: Estimates from U. S. national surveys, 2002. Spine, 31, 2724-277.

2. Hart, L. G., Deyo, R. A., & Cherkin, D. C. (1995). Physician office visits for low back pain: Frequency, clinical evaluation, and treatment patterns from a U. S. national survey. Spine, 20, 11-19.

3. Andersson, G. B. (1999). The epidemiologic features of chronic low back pain. Lancet, 354, 581-585.

4. Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., Castel, L. D., Kalsbeeck, W. D., & Carey, T. S. (2009). The rising prevalence of chronic low back pain. Archives of Internal Medicine, 169, 251-258.

5. Agency for Healthcare Research and Quality. (2009). Total expenses and percent distribution for selected conditions by type of service: United States, 2009. Washington DC: Government Printing Office. 

6. Center for Disease Control. (2009). Prevalence and most common causes of disability among adults – United States, 2005. Washington DC: Government Printing Office. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5816a2.htm

7. Cote, P., Cassidy, J. D., & Carroll, L. (2001). The treatment of neck and low back pain: Who seeks care? Who goes where? Medical Care, 39, 956-967.

8. Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331, 69-73.

9. Powell, M. C., Szypryt, P., Wilson, M., Symonds, E. M., & Worthington, B. S. (1986). Prevalence of lumbar disc degeneration observed by magnetic resonance in symptomless women. The Lancet, 328, 1366-1367.

10. Takatalo, J., Karppinen, J., Niinimaki, J., Taimela, S., Nayha, S., Jarvelin, M. R., Kyllonen, E., Tervonen, O. (2009). Prevalence of degenerative imaging findings in lumbar magnetic imaging among young adults. Spine, 34, 1716-1721.

11. Chou, R., Aseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147, 478-491.

12. Chou, R., & Huffman, L. H. (2007). Medications for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Annals of Internal Medicine, 147, 505-514.

13. Carey, T. S., Freburger, J. K., Holmes, G. M., Castel, L., Darter, J., Agans, R., Kalsbeek, W., & Jackman, A. (2009). A long way to go: Practice patterns and evidence in chronic low back care. Spine, 34, 718-724.

Date of publication: April 27, 2012

Date of last modification: October 23, 2015