Cathryn Jakobson Ramin’s back pain started when she was 16, on the day she flew off her horse and landed on her right hip.
For the next four decades, Ramin says her back pain was
like a small rodent nibbling at the base of her spine. The aching left
her bedridden on some days and made it difficult to work, run a
household, and raise her two boys.
By 2008, after Ramin had exhausted what seemed like all
her options, she elected to have a “minimally invasive” nerve
decompression procedure. But the $8,000 operation didn’t fix her back,
either. The same pain remained, along with new neck aches.
The big takeaway: Millions of back patients like Ramin are floundering in a medical system that isn’t equipped to help them. They’re
pushed toward intrusive, addictive, expensive interventions that often
fail or can even harm them, and away from things like yoga or
psychotherapy, which actually seem to help. Meanwhile, Americans and
their doctors have come to expect cures for everything — and back pain
is one of those nearly universal ailments with no cure. Patients and
taxpayers wind up paying the price for this failure, both in dollars and
in health.
Thankfully, Ramin finally discovered an exercise program
that has eased her discomfort. And to this day, no matter how busy her
life gets, she does a series of exercises every morning called “the
McGill Big Three” (more on them later). “With very rare exceptions,” she
says, “I find time to exercise, even when I’m on the road.”
More and more people like Ramin are seeking out
conservative therapies for back pain. While yoga, massage, and
psychotherapy have been around for a long time, there was little
high-quality research out there to understand their effects on back
pain, and doctors sometimes looked down on these practices. But over the
past decade, that’s changed.
To learn more, I searched the medical literature on
treatments for lower back pain (the most common type) and read through
more than 80 studies (mainly reviews of the research that summarized the
findings of hundreds more studies) about both “active” approaches
(yoga, Pilates, tai chi, etc.) and passive therapies (massage,
chiropractics, acupuncture, and so on). I also talked to nine experts
and researchers in this field. (For more detail on our methods, scroll
to the end.)
What I found surprised me: Many of these approaches
really do seem to help, though often with modest effects. But when you
compare even those small benefits with the harm we’re currently doing
while medically “treating” back pain, the horror of the status quo
becomes clear. “No one dies of low back pain,” one back pain expert,
University of Amsterdam assistant professor Sidney Rubinstein, summed
up, “but people are now dying from the treatment.”
Mainstream medicine has failed people with chronic back pain
Lower back pain is one of the
top reasons people go to the doctor in the US, and it affects 29 percent of adult Americans, according to surveys. It’s also the
leading reason for missing work anywhere in the world. The US spends approximately
$90 billion a year on back pain
— more than the annual expenditures on high blood pressure, pregnancy
and postpartum care, and depression — and that doesn’t include the
estimated $10 to $20 billion in lost productivity related to back pain.
Doctors talk about back pain in a few different ways, but the kind most people (
about 85 percent)
suffer from is what they call "nonspecific low back pain." This means
the persistent pain has no detectable cause — like a tumor, pinched
nerve, infection, or
cauda equina syndrome.
About 90 percent of the time, low back pain is
short-lived (or in medical lingo, “acute”) and goes away within a few
days or weeks without much fuss. A minority of patients, though, go on
to have subacute back pain (lasting between four and 12 weeks) or
chronic back pain (lasting 12 or more weeks).
Chronic nonspecific back pain is the kind the medical
community is often terrible at treating. Many of the most popular
treatments on offer from doctors for chronic nonspecific low back pain —
bed rest,
spinal surgery,
opioid painkillers,
steroid injections — have been proven ineffective in the majority of cases, and sometimes downright harmful.
Here’s the outrageous part: All these opioids were being prescribed before we
actually knew if they helped people with chronic lower back pain. It
gets worse: Now high-quality evidence is coming in, and opioids don’t
actually help many patients with chronic low back pain.
This soon-to-be-published randomized controlled trial
was the first to compare the long-term use of opioids versus non-opioid
medications (such as anti-inflammatory drugs and acetaminophen) for low
back pain. After a year, the researchers found opioids did not improve
patients’ pain or function, and the people on opioids were actually in
slightly more pain compared to the non-opioid group (perhaps the result
of
“opioid-induced hyperalgesia” — heightened pain brought on by these drugs).
As for surgery, only a small minority of patients with chronic low back pain require it, according to
UpToDate,
a service that synthesizes the best available research for clinicians.
In randomized trials, there was no clinically meaningful difference when
comparing the outcomes of patients who got spinal fusion (which has
become more and more popular in the US over the years) with those who
got a nonsurgical treatment.
Steroid injections for back pain, another popular medical treatment, tend to have
similarly lackluster results: They improve pain slightly in the short term, but the effects dissipate within a few months. They also
don’t improve patients’ long-term health outcomes.
It’s not entirely surprising that the surgeries,
injections, and prescription drugs often fail considering what
researchers are now learning about back pain.
Historically, the medical community thought back pain
(and pain in general) was correlated to the nature and severity of an
injury or anatomical issue. But now it’s clear that what’s going on in
your brain matters too.
“Our best understanding of low back pain is that it is a
complex, biopsychosocial condition — meaning that biological aspects
like structural or anatomical causes play some role but psychological
and social factors also play a big role," Roger Chou, a back pain expert
and professor at Oregon Health and Science University, summarized.
For example, when you compare people with the
same MRI results showing the same back injury
— bulging discs, say, or facet joint arthritis — some may experience
terrible chronic pain while others report no pain at all. And people who
are under stress, or prone to depression, catastrophizing, and anxiety
tend to suffer more, as do those who have histories of trauma in their
early lives or poor job satisfaction.
The awareness about the role psychological factors play
in how people experience pain has grown more widespread with the general
shift away from the dualist view of the mind and body toward the more
integrated
biopsychosocial
model. Chronic nonspecific low back pain “should not been considered as
a homogenous condition meaning all cases are identical,” researchers in
one review of the research on exercise cautioned.
A new understanding of pain called
“central sensitization”
is also gaining traction. The basic idea is that in some people who
have ongoing pain, there are changes that occur between the body and
brain that heighten pain sensitivity — to the point where even things
that normally don’t hurt are perceived as painful. That means some
people with chronic low back pain may actually be suffering from
malfunctioning
pain signals.