You probably know that back surgery is one of the most “overperformed” operations in the US. In fact, up to half of the 400,000 back surgeries that take place in the US each year don’t work or are unnecessary. With time, many of these back patients would have improved without surgery. But there is an underlying cause that often can be treated—perhaps more effectively than ever before.
What you need to know…
Many specialists who treat back pain (mainly orthopedists and neurosurgeons) tend to look for structural problems, such as a herniated disc. Most doctors are far less likely to consider the role of muscle injuries, which are harder to detect but often are the real culprit.
If you go to your doctor complaining of back pain, there’s a good chance that you’ll be told to get an imaging test, such as an MRI or a CT scan. If the test identifies a herniated disc or spinal stenosis (a narrowing of the spinal canal), surgery may be appropriate—for example, if the back pain is severe, intractable and radiates into a leg (sciatica)…gets progressively worse over a period of weeks or months…and/or is accompanied by loss of bowel or bladder control.
However, it’s common for an imaging test to show a herniated disc or another structural abnormality, even in cases in which it is not the cause of the back pain.
Important finding: In a study of more than 20,000 back patients, 70% to 80% had muscle or soft-tissue injuries, which cannot be reliably identified with standard tests. Many of these patients receive back surgery for a structural problem when a muscle injury is really to blame.
Here’s what happens: When muscle fibers are damaged—from overuse or stress-related tension, for example—they release chemicals that stimulate nerve receptors. The nerves then release highly inflammatory chemicals that constrict blood vessels and reduce the circulation of blood and oxygen to the affected area.
Without treatment, the muscle nerve receptors become sensitized—that is, they continue to cause pain even when you are doing things that shouldn’t be painful (such as standing up). The pain can persist long after the original injury is gone.
The most common diagnosis for back patients is “nonspecific low-back pain.” This is just a fancy way of saying that the cause of the pain is unknown. During an evaluation, your doctor might feel (palpate) the muscles in your back to identify areas with tightness or spasms. In addition, he/she might ask you to move your body in specific ways to determine which of the muscles may be affected. But these approaches are not precise and generate only guesses about the source of the back pain.
Recent development: A new handheld electrical-stimulation unit, which is expected to be commercially available within the next year, determines whether a muscle injury is the cause of a person’s back pain.*
Here’s how it works: While the patient is lying down, the device is swept along the entire length of muscles that are suspected of causing back pain. An electrical current from the unit causes the muscles to contract. No pain during the contraction means that the muscle is not the cause of the back pain. If pain occurs during stimulation, the muscle is likely causing the back pain and will need treatment. Randomized, double-blind research published in Pain Medicine found that the device is a more effective method than palpation for identifying a muscle that’s causing pain.
Even if your back pain is due to a minor muscle injury, don’t make the major mistake of ignoring it. With new pain, you need to interrupt the cycle of injury—muscle tension followed by inflammation, then more tension, as well as inflammation and pain—before the nerves become sensitized and cause chronic pain. If you have chronic pain, the same approaches can reverse the problems that perpetuate pain. Key steps…
Start local treatments, such as applying a cold pack for three to five minutes (until the area becomes numb) every few hours, as soon as the pain starts. Continue this for one to three days. Cold is used to diminish pain and swelling, thus helping to facilitate movement. The pain relief lasts longer than when heat is used—perhaps due to increased blood flow when the ice is removed. In addition, massage will help promote circulation to the affected area and flush out tissue-damaging chemicals. A massage therapist (or a friend or family member) should begin with gentle pressure, then slowly (and painlessly) increase pressure on tender areas.
Also helpful for pain: Ibuprofen (Motrin) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that help protect the muscle from ongoing irritation. Take only for a few days—longer use can lead to side effects. For example, if you have stomach ulcers, gastrointestinal bleeding, kidney failure or asthma, NSAIDs can worsen your condition. If you prefer a natural approach, there is moderate (though inconclusive) evidence that such remedies as devil’s claw and vitamin B-12 injections decrease pain.
Consider muscle injections. This treatment often reduces back pain immediately and allows you to begin exercising. For that reason, I recommend muscle injections for most back patients who have had pain for more than three months.
What’s involved: Most patients with back pain have four or five muscles that are affected. An injection is given into each of the muscles, usually over a period of about two weeks. I use lidocaine in the shots to reduce the discomfort. Some doctors inject other substances, such as steroids, Botox or saline. Studies indicate that the “needling” is the important part of the treatment—the actual substance that’s injected doesn’t affect the treatment.
How it works: Inserting a needle into muscle fibers causes a local injury to the pain-producing muscle fibers. The fibers respond to the injury by growing new tissue. There is also an increase in circulation, which flushes away pain-causing chemicals.
Do deep breathing. This is more effective than you might think. Reason: Chronic stress triggers the release of excessive levels of epinephrine, a so-called stress hormone. It causes muscles to contract and shorten, which increases pain. Patients who learn to relax for a few minutes each day experience a decrease in epinephrine and an increase in muscle relaxation.
What to do: Lie on your back with your knees slightly bent and your feet flat on the floor. Breathe in through your nose so that your stomach expands—your chest shouldn’t move. Then, fully exhale from your mouth as your stomach flattens. Repeat this breathing-exhaling cycle three times. Take a moment to feel the sensations of relaxation.
Exercise daily. It is among the most effective treatments for lower-back pain. In a 12-year study, more than 300,000 participants with back pain performed simple daily exercises and stretches. Within six weeks, 81% reported that their pain was either reduced or gone. In a study published in The Spine Journal, even a single workout was found to temporarily reduce back pain by 10% to 50%. Possible reason: People who exercise daily have healthier, stronger muscles and more endurance for prolonged activity.
I recommend a series of stretching/strengthening exercises, which includes shoulder shrugs, head rolls and raising your knees to your chest. Mild, transient pain may occur during any exercise routine, but you should not repeat exercises that cause a lot of pain or pain that persists.
Also helpful: In addition to stretching and strengthening exercises, aerobic activity is very effective for back pain, as long as it doesn’t increase your pain or cause excessive fatigue. Good choices include walking, swimming and biking.
*Dr. Marcus is the inventor of this device and will have a financial interest in its commercial manufacture.
