Neck and back pain
Lower back pain is very common. There are many different ways to treat it -- part of which is due to the fact that none of them are the perfect treatment for all patients.
When someone presents with back pain or neck pain, there are several important issues that need to be considered. First, has there been any trauma which would lead to a fracture. Second, is there any sign of infection or cancer. Third, are there any symptoms such as bladder or bowel problems or weakness or is there only pain. The possibility of cancer, infection, or fracture can be set aside and ruled out with a set of regular x-rays and a history and physical examination.
Assuming that pain is a major problem and that there is no evidence of fracture, infection, or cancer, then the next issue is how to help the patient. This is divided into three phases.
In the first phase, we have to relieve the pain. For mild pain, I use Tylenol (acetaminophen). The Tylenol dose is one to two 325 mg Tylenol every six hours or one extra strength (500 mg) Tylenol every six hours such as a 12am, 6am, 12noon, 6 pm schedule. If necessary (if the pain is not relieved by Tylenol alone), I add a non-steroidal anti-inflammatory agent such as Naprosyn (naproxen) 250 to 500 mg every 12 hours. If needed, I will give naproxen in a dose of 250 mg every six hours on a 3 a.m., 9 a.m., 3 p.m., 9 p.m. schedule if a 12 hour schedule does not forstall the pain. In that manner, you can take something every three hours for pain. It should be noted that all nonsteroidal medications can hurt the kidneys, stomach and heart if taken in excess. Also, despite recent bad press, they are probably safe taken as short term (days) treatment. Naproxen appears safest of all the non-steroidals for heart patients.
If stronger pain relievers are necessary, I substitute Tylenol # 3 or 4 (Tylenol with codeine) one to two tablets every six hours at 12, 6, 12, 6 instead of regular Tylenol. Do not take Tylenol and Tylenol with codeine because that is too much Tylenol. Also, in addition to being habit forming, codeine can cause constipation so make sure to take a stool softener, fiber, or prunes if you are taking Tylenol with codeine.
Sleeping pills may be necessary. Time off work may be necessary. The pain may be agonizing and frequent contact with the doctor may be necessary. During this phase, the patient is encouraged to find positions are comfortable and to minimize activities to minimize pain. For many people, lying flat on their back is the most comfortable position. Until the pain is completely gone, activity is minimized to minimize pain. Physical therapy, chiropractic manipulation etc. are all deferred at this stage.
In the second phase, pain is all gone and healing must occur. Again, physical therapy must be deferred for healing to occur. In this stage, the patient is taught how to use his/her back so that he does not continue to injure it. It is important to learn how to move the body in such a way that it does not continue to reinjure the area that is in pain. The key concepts here involve learning how to move the feet and turn the entire body rather than twisting, learning to avoid reaching or stretching (and using step stools or other devices to avoid stretching and reaching), and lifting only small amounts and using correct technique. If one doesn't do this, there is virtually no chance that the back will heal. Also, during this period, nonsteroidals need to be continued in order to decrease inflammation (Tylenol does not have any anti-inflammatory effect and is used only for pain).
In the third phase, the back has been given a chance to heal for several months and pain is gone for three months. At this point, physical therapy needs to be started to strengthen the abdominal muscles and back muscles. Situps are key but need to be done correctly. Back and abdominal exercises need to be taught so that further injury does not occur. The third phase last indefinitely and the patient is taught how to do these exercises safely and forever. The lessons learned in phase two -- avoiding reaching and stretching, lifting correctly and only with reasonable amounts of weight, and learning to avoid twisting by turning the entire body -- are also carried over.
This regimen will fix over 90% of back pain. As long as there is no motor weakness or bladder or bowel problems, this will work. Some patients may need a brace for their back or neck in phase two if they are unable to keep themselves from reinjuring their back or neck. Surgery and MRI scans are reserved for those who are suspected to have a fracture, cancer, infection, or a neurologic abnormality such as weakness. Numbness and pain are in general not sufficient reasons to warrant expensive tests or surgery.