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I Still Have Back Pain! Now What?

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Does the following sound familiar? You injured your back quite some time ago. You went to your doctor and initially some medications were prescribed and some physical therapy. The physical therapy either did not help much or in fact it made you worse. After several weeks to months of trying physical therapy you had further testing including x-rays or maybe an MRI scan. After these tests you may have been referred for some special steroid injections into your back of which you had at least three. These may have helped temporarily, but did not significantly resolve the severe pain you are having. Eventually, you underwent surgery. Then after a period of rehabilitation you may have felt some improvement particularly if you had had some pain in your leg. However, you continue to have significant pain in your lower back. By this time many months have past and you are not able to do the things you enjoy and may not have been able to return to work. You are now trying many different medications including opiate containing medications. You have been to see many doctors but what they are telling you is there is not much else they can do for you and what you need to do is learn to live with your pain.

You would be a rare individual indeed if you were not somewhat frustrated, angry, and even depressed at this point. If any of this sounds familiar, please read on because there may be some things that can be done to help you. Chronic back pain can be a challenge to treat, but you do have options. To help you learn about these options, you may take our Chronic Pain Treatments Quiz.

Multidisciplinary Approach
The first thing I would suggest is to stop looking for a solution. I am not being facetious. What I am talking about is when you fall into the unfortunate circumstance of suffering from chronic low back pain we have found that there is no single solution to the problem. Instead multiple interventions need to be utilized to improve your condition. This is termed a ‘multidisciplinary’ approach. Often a combination of different treatments may help even if some of these treatments have been tried before but not in the same combination. This point cannot be emphasized enough.

Understanding Pain
Another very important step toward getting better is to understand what pain is. Most of us, including health care professionals, have a very simplistic view of what pain is. Pain to us means there is something that has been damaged or is about to be damaged.

A specialized nerve ending senses this pain and sends a message to our spinal cord and up to our brain where we then realize the pain. After all, isn’t this why we need pain? So that we can tell when we are injuring ourselves or when we are about to injure ourselves. However this simplistic view of pain does not explain why -- when your doctor has told you there is nothing they can find wrong -- and the surgery has removed what has been causing damage -- and you are all healed and -- yet you still have pain.

Pain and Neurotransmitters
This view of pain also does not explain why when we are frustrated or angry our pain seems to be much worse. And when we are distracted, such as watching a movie or engrossed in good conversation our pain may be somewhat less. A new concept of pain is emerging that can explain these things. This concept is based on the fact that there are naturally occurring chemicals used by our nervous system to transmit pain messages. These things are called ‘neurotransmitters’ and there are many different types. Some of these neurotransmitters such as endorphins, which you may have heard of, can help decrease pain. There are other neurotransmitters that may increase pain.

One theory in regards to chronic pain is that the nervous system has an imbalance of these naturally occurring neurotransmitters. The ones that help decrease pain do not seem to be working as well --- and the ones that increase pain seem to be working in excess. It is almost as though a chemical switch has been turned on that doesn’t turn off. In these situations, the pain message being sent does not signify that something is being damaged or is about to be damaged. Thus it is not a useful message for us and the system is not working the way it should.

Or you may find yourself in a situation where you do have a disease process such as degenerative arthritis, which is continuing to send pain messages. However these pain messages are also not useful because there is nothing we can particularly do about the arthritis. This theory of chronic pain being an imbalance of chemical neurotransmitters also will explain how our emotional state and behaviors can affect our pain.

Effects of Behavior and Emotions
Our behaviors as well as our emotional state changes the chemistry in our nervous system thus either enhancing or diminishing our pain. With this new, much more complex concept of what pain is, we can then understand that there are many other approaches that may help manage the chronic pain that you may be suffering from.

Complementary Interventions
Many useful interventions may be things we would not associate with medical treatment. These things are also referred to as ‘complementary’ and ‘alternative’ medicines. I prefer the term ‘complementary’ because this implies multiple interventions, which includes traditional medical interventions. I have found this to be the best approach for the patient suffering from chronic pain.

A combination I often recommend for patients is to utilize gentle massage to reduce painful muscle spasms. In addition to this, weekly acupuncture treatments seem to significantly help to reduce pain.

Acupuncture is the insertion of tiny sterile needles into the skin at specific points based upon some Chinese medicine principles. In Chinese medicine, acupuncture is used to create a balance of an energy force called the Chi (pronounced ‘chee’) within the body. From a scientific standpoint, it has been shown to alter those naturally occurring neurotransmitters, which we talked about.

In addition to massage and acupuncture, some gentle movement-based therapies are often effective. Often times your pain may be so bad that traditional exercise just aggravates it. However, we do know that exercise is very beneficial in decreasing pain because it also changes those neurotransmitters.

A good way to get some gentle exercise is to utilize techniques such as Tai Chi, Yoga, or Pilates. Tai Chi is also based upon Chinese medicine principles and utilizes slow rhythmic movements to increase strength, balance, endurance, and mobility. Yoga utilizes breathing and relaxation techniques to also increase mobility and strength. Pilates is a technique that is very popular with dancers which seems to be particularly effective for people with lower back pain. It is also a combination of gentle strengthening and stretching, which particularly helps strengthen the lower back and abdominal musculature.

Emotional Consequences of Pain
In addition to addressing the physical components of pain, it is important not to overlook the emotional consequences of chronic pain. Anger, frustration, and depression will alter your neurochemistry to actually increase your pain. However, with a combination of meditation, breathing techniques, and psychological counseling to teach coping strategies, these emotional consequences can be effectively treated.

For some of my patients I even recommend such things as humor therapy or making sure they do something daily that they enjoy such as dancing. These things are actually very accessible. You can watch something funny on TV, rent a funny movie or read something humorous. Likewise it is simple to listen to music and move gently to the music even if in a seated position. Interestingly enough, these things have been studied and have been shown to also change those neurotransmitters in a positive way to help decrease pain.

Feeling Better
A combination of these interventions with more traditional interventions may not eliminate your pain completely, however many chronic pain patients find that they feel quite a bit better and then are able to be more active, do the things that they like do and enjoy their lives. In other words, they do learn to live with their pain.

Updated on: 03/26/10
David S. Bradford, MD
Over the past decade, complementary and alternative medicine innovations have received increased awareness and interest by the medical as well as the lay community. In part, this could be explained by an article by David Eisenberg, published in the New England Journal of Medicine in 1993, which stated that over 30% of the U.S. population had sought unconventional medical treatments in the preceding year. This outnumbered all the visits to primary care providers that same year. It is estimated that over $13 billion was spent, and that now over 40% of the population has sought alternative interventions with currently over $27 billion being spent each year. This does not appear to be due to dissatisfaction with conventional medicine and is not predictive of the use. Rather, patients want to address their health and medical issues with a variety of methods that go along with their own values, beliefs, and philosophical orientations toward life and health. At the University of California at San Francisco, many physicians are actively exploring a variety of complementary and alternative medicine interventions in an effort to better understand them and to provide safer, more effective medical treatment for their patients. Dr. Ward Gypson, a faculty member in the Department of Orthopaedic Surgery at UCSF, is a specialist in physical medicine rehabilitation and provides expertise within our department as well as a clinic for patients seeking alternative and complementary interventions.
Gerard Malanga, MD
The article by Dr. Gypson represents a progressive approach in the management of chronic pain problems. These problems must be addressed in a multidisciplinary fashion rather than a one dimensional approach such as multiple injections, spinal adjustments, passive modality therapy or even surgery. The patient must be an active participant in his or her management of the pain. Thereby, the locus of control is changed form the medical providers to the patient. Alternative medicine techniques can be helpful and the scientific basis for their use is increasing. The question that some times arise is whether insurance companies should cover these treatments. Studies that demonstrate the cost effectiveness of these treatment will be helpful in this area. This would include studies that demonstrate a decreased need for prescription pain medications which can be costly and are often associated with various side effects. In the end, the key aspect that patients must understand is that while a "cure" for their chronic pain is not likely, they can learn to manage their pain and live full, active lives.
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