An Integrative Apprach t Lw Back Pain Hw cmmn is lw back pain? Lw back pain is very cmmn. Abut 75% f individuals (three ut f every fur peple) will experience lw back pain at sme pint in their lives. It is ne f the mst frequent reasns fr clinic visits. What causes lw back pain? There are many causes fr lw back pain. Sme f the mst cmmn nes include: accidents, injuries, tight muscles frm the hassles f daily life, and changes in the bdy due t getting lder and/r being verweight. Only abut 3% (3 ut f 100 peple) will have lw back pain frm cancer, infectin, r diseases in ther rgans. Stress can affect hw strng the pain is and hw lng it lasts. When shuld I see a clinician fr lw back pain? Usually back pain ges away n its wn, and yu d nt need t see a clinician. It is a gd idea t make a clinic appintment if: yur pain is severe the pain des nt get better ver time yur pain is frm a fall r an injury yu have had cancer yu have any f the fllwing alng with back pain: truble urinating; weakness, pain, numbness, r tingling in yur legs; fever; r unplanned weight lss. Curtesy: NIAMS Hw lng des back pain last? Lw back pain can be acute, lasting less than six weeks, r chrnic, lasting lnger than three mnths. If it is chrnic, yu might feel it all the time, r it might cme-and-g. Mst peple (60%) wh have acute pain recver in ne week. Sixty t 90% f patients recver in six weeks. Ninety-five percent f patients recver in 12 weeks. Of cncern, back pain tends t recur within six mnths fr 40% f patients. Hw is lw back pain treated? Lw back pain is treated in a variety f ways. 1. Acute pain usually ges away n its wn. It is imprtant t stay active, and nt lie in bed. The fllwing appraches may help yu feel mre cmfrtable: take ver-the-cunter pain medicatin apply heat t the back, then ice, then heat again (Apply each fr 20 minutes. Prtect yur skin, s yu d nt burn r freeze it. D this tw r mre times per day.) receive therapy frm a chirpractr r stepathic physician. (An stepathic physician uses her/his hands t mve yur muscles and jints by stretching, using gentle pressure and resistance. This is called setepathic manipulative treatment r OMT). PATIENT HANDOUT 1 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain 2. See yur primary care clinician if yur pain des nt imprve. Yur clinician will determine if yu need further testing t search fr a specific cause fr yur pain. If a cause is fund, ask abut yur ptins fr treatment. 3. Receive treatment fr chrnic pain. If a specific reasn is nt fund fr yur pain, it is then imprtant t start treatment early t prevent lng-term pain and disability. There are a number f treatments fr chrnic pain. Sme are expensive and may nt help all that much. Als they may nt be safe t use lng-term. Chrnic severe lw back pain is ften treated with narctic medicatin called piids. Recent research suggests that this may nt be the best apprach fr peple withut cancer. Lng-term use f piids may even increase pain, because the medicine can make yu mre sensitive t it. In Denmark, ver 10,000 patients with chrnic pain wh did nt have cancer participated in a study testing lng-term piid treatment. Researchers fund that verall this drug treatment did nt prvide relief frm pain, did nt imprve patients qualify f life, and did nt imprve their ability t functin. Other prblems with piid medicatin include: side effects, the pssibility f misusing r abusing the drug, and a need fr larger dses ver time. Even verdse and death can ccur. Als, by taking a narctic drug, yu may nt learn what will help yur bdy heal. Evidence-based medicine is treatment based n the best available infrmatin learned thrugh research r experience. The Natinal Institute f Clinical Excellence (NICE) in the United Kingdm recmmends the fllwing evidence-based treatments t manage lw back pain: manual therapy, acupuncture, nn-steridal anti-inflammatry drugs, psychlgical therapy and exercise. A study reprted in 2008 f warehuse wrkers with lw back pain fund that a cmbinatin f acupuncture, relaxatin exercises, exercise, dietary advice, and a back care bklet was mre helpful than a cmbinatin f nly physical therapy educatin and a back care bklet. In the lng-run, the treatment invlving the acupuncture als cst less. Hw des Integrative Medicine treat back pain? Our integrative apprach has three gals 1. t encurage yu t assume an active rle in yur care 2. t decrease yur pain and increase bth yur ability t functin and yur quality f life 3. t prevent chrnic disability while reducing yur need fr lng-term therapies such as medicatins, injectins r manipulatin. In this handut, we will share ur evidence-based suggestins fr managing lw back pain. This apprach invlves: A team f helping prfessinals. Yu may wrk with several different specialists. Guidance frm yur medical hme. It is best if yur care is managed by yur primary care clinician r a health cach cmmunicating clsely with yur primary care specialist. Research has shwn that having yur care managed by a clinician wh knws yu well can imprve yur care and reduce cst. If needed, yur clinician can prescribe pain medicatin and/r refer yu t a pain clinic while cntinuing t fllw-up with yu. PATIENT HANDOUT 2 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Patient-centered care. N therapy fr lw back pain has been fund t be better than anther. When this is the case, yur treatment may be mre successful if yu are able t chse ptins that fit best with yur interests, daily schedule, and yur beliefs. Treatment Appraches We have rganized treatment recmmendatins int three categries: 1. External/Physical (which includes Chirpractic, Ostepathic Manual Therapy, Massage Therapy, Acupuncture and nn-steridal anti-inflammatry drugs [such as ibuprfen r naprxen sdium]) 2. Internal/Emtinal 3. Recnditining (strength and supprt) Wrk with yur primary care clinician t chse ne therapy frm each f the three grups fr yur treatment plan t help reduce chrnic pain. The ptins yu chse and the timing f each is up t yu and yur clinician. 1st Therapy Grup Optins External/Physical Direct frce t jints f the spine. The hands-n wrk dne by chirpractrs and stepathic physicians can invlve bth direct and indirect techniques. Direct techniques use frce t restre mtin t a jint. This invlves mvement past the range that yu can d yurself. Direct techniques f the spine have been fund t imprve pain and the ability t mve. All majr internatinal medical guidelines recmmend it as a treatment ptin fr bth acute and chrnic lw back pain. Yu are mst likely t be helped by this apprach if yu have had pain fr less than 16 days, yu d nt have symptms that travel belw yur knees, and yu d nt avid mvement because yu fear the pain will becme wrse. Matthew Lester Curtesy: NCCAM Indirect manual therapy and muscle energy techniques. Indirect techniques stay within the range f mtin that yu can d yurself. They include: strain-cunterstrain: briefly mving the tender area t a psitin f greater cmfrt and then returning t the riginal psitin myfascial release: gentle pressure applied ver time int the fascia (the bdy s cnnective tissue). This helps the fascia t becme lnger and mre relaxed, while eliminating pain and restring mtin. spine mbilizatin: gentle mvement f the jint t restre nrmal mtin crani-sacral therapy: very light tuch used t balance the bnes, nerves, fluids, and cnnective tissue f the head and spinal area. In muscle energy therapy, yu are guided t use yur muscles in a directin ppsite f pressure applied by the clinician. These techniques are used by many different clinicians including stepathic physicians, chirpractrs, physical therapists and massage therapists amng thers. Indirect techniques are helpful fr bth acute and chrnic lw back pain. PATIENT HANDOUT 3 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Massage. Massage therapy invlves mving the sft tissues f the bdy, returning them t nrmal. Therapists use their hands, frearms r elbws t apply pressure, hld, r cause the bdy t mve. There are different types f massage fr different purpses. Therapists tailr their apprach t match each patient s unique needs. Massage has been fund t be similar t exercise in imprving back pain and functin. In a study n chrnic lw back pain, UW-Madisn Integrative Medicine Prgram 401 patients were assigned t ne f three treatment grups: 1) structural massage, 2) relaxatin massage and 3) usual care. After 10 weeks, patients wh received either type f massage culd mve better and had fewer symptms than thse wh received usual care. These benefits lasted up t six mnths. One type f massage was nt better than the ther. Acupuncture Acupuncture invlves inserting very thin, sharp sterile needles int the skin. The needles are placed in specific spts in the bdy. Acupuncture imprves the flw f energy and fluids in the bdy. The bdy can get ut f balance, and the energy called qi (prnunced chee) becmes blcked. Discmfrt r pain can ccur when qi is blcked. Acupuncture helps unblck qi. It als helps release the bdy s natural painrelievers. Acupuncture can reduce pain and imprve functin. It appears t wrk better when cmbined with ther therapies such as spinal manipulatin and exercise therapy. In a study f 298 patients with chrnic lw back pain, acupuncture and "minimal acupuncture was cmpared t n treatment. ( Minimal acupuncture invlved lightly placing needles at places n the bdy nt knwn t be helpful.) After 12 sessins ver eight weeks, peple in bth acupuncture grups experienced less pain than the patients wh did nt receive treatment. These benefits lasted up t a year. Acupuncture appears t be mre helpful fr chrnic lw back pain than fr acute lw back pain. Evidence shws that acupuncture helps mre ver the lng-term and is less likely t cause harm than epidural sterid injectins, which are a cmmn treatment fr lw back pain. Nn-Steridal Anti-Inflammatry Drugs (NSAIDs) NSAIDs are medicatins used t help cntrl pain and inflammatin. Many, such as aspirin and ibuprfen, are available ver-the-cunter withut prescriptin. One side effect is an increased risk fr bleeding. 2nd Therapy Grup Optins Internal/Emtinal Pain can affect yur md, and yur md and stress can affect yur pain. It is imprtant fr anyne with chrnic lw back pain t lk at these mind-bdy cnnectins. Research has shwn that therapy fcussing n hw peple with chrnic lw back pain think and feel emtinally can reduce pain, depressin, and disability and increase their quality f life. PATIENT HANDOUT 4 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Studies dne t see if patients with lw back pain were candidates fr surgery shwed surprising findings. Researchers lked at x-rays after injecting dye int the space arund discs. (Discs are the cushins between the bnes f the spine the vertebrae.) They fund that the degree f pain a patient reprted was nt related t hw much a disc in the spine bulged r ruptured but rather t hw much distress the patient reprted. Many peple wh have bulging r ruptured discs n x-ray d nt have pain. The disc may be blamed when at times the true cause f the pain may be a persn s distress. There are a number f mind-bdy therapies which yu can cnsider. Cgnitive Behaviral Therapy (CBT). CBT is a frm f psychtherapy that fcuses n hw peple think. It is based n the idea that individuals feelings and behavirs are influenced by their wn thughts, nt by ther peple r situatins. This therapy helps peple change the way they think abut whatever is bthering them, s they can feel and act better, even if the situatin des nt change. One study lked at 213 individuals with chrnic lw back pain five years after treatment. It shwed that thse wh received CBT had reduced pain, and increased physical activity, quality f life and general health. They als missed fewer days f wrk. Many psychlgists, clinical scial wrkers, and ther cunselrs prvide this therapy. It may be especially helpful t chse a prfessinal wh is experienced in pain management. PATIENT HANDOUT 5 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Emtinal Awareness. Keeping yur emtins bttled up inside when yu are stressed, rather than expressing them, can cause physical pain t feel wrse. William Byd MD, a pathlgist at the turn f the 20th century, said, The srrw that hath n vent in tears may make ther rgans weep. This has prven true in the treatment f lw back pain. Jhn Sarn MD has written several helpful bks n hw back pain can be reduced r healed thrugh recgnizing stress and dealing with emtins in a psitive way. Bks by Jhn Sarn MD, n Emtinal Awareness Healing Back Pain: The Mind-Bdy Cnnectin (1991) Warner Bks, Inc. The Mind-Bdy Prescriptin (1998) Warner Bks, Inc. The Divided Mind (2006) HarperCllins Publishers There are many reprts f individuals with chrnic lw back pain wh have been helped by this apprach. Hwever, there has been little research n Sarn's methd. One grup f 51 patients with chrnic lw back pain were fllwed frm 3-12 mnths after cmpleting a curse that encuraged them t be aware f the relatinship between their pain and bttled up stress. Their pain was reduced by an average f 52%. They als needed less medicatin, and they became mre active. Thse wh had pain fr mre than three years were helped the mst. Hward Schubiner is a leader in ffering Emtinal Awareness Therapy. See his resurces at: Mind/Bdy Awareness Writing Exercise n the University f Wiscnsin- Madisn Department f Family Medicine Integrative Medicine website. (http://www.fammed.wisc.edu/sites/default/files//webfmuplads/dcuments/utreach/im/handut_mbs_wrkbk.pdf) http://www.unlearnyurpain.cm/ Mindfulness Meditatin. Mindfulness is the prcess f bringing awareness t the present mment withut judgment. Instead f distracting yurself away frm pain, mindfulness teaches yu t bring yur attentin t it. (Fr mre infrmatin n this apprach, see ur handut Meditatin fr Health and Happiness.) Studies have used magnetic resnance imaging (MRI) t shw that multiple areas f the brain are affected when mindfulness meditatin is used fr pain. (MRI is a prcedure in which radi waves and a pwerful magnet linked t a cmputer are used t Bb Stckfield Curtesy:NCCAM create detailed pictures f areas inside the bdy). Mindfulness wrks in part by helping peple reduce their fear and anxiety. Patients with chrnic pain wh have lw mindfulness scres tend t be mre fearful and wrry mre abut pain. PATIENT HANDOUT 6 University f Wiscnsin Integrative Medicine
Pain An Integrative Apprach t Lw Back Pain There are few studies f mindfulness fr chrnic lw back pain. One prject studied 37 adults lder than age 65 with chrnic lw back pain. It fund that thse wh practiced mindfulness meditatin had less pain and better functin cmpared t peple in a cntrl grup wh did nt d the meditatin. Anther study cmpared an eight-week mindfulness-based- stress-reductin prgram (MBSR) with a prgram invlving eight weekly educatinal sessins n chrnic pain frm a nurse, physical therapist and dietician. After three mnths, peple in bth grups were fund t have less pain and distress. One apprach was nt better than the ther. Yu can lcate MBSR classes thrugh clinics, hspitals, r a website maintained by the University f Massachusetts Medical Schl s Center fr Mindfulness: http://w3.umassmed.edu/mbsr/public/searchmember.aspx. NOTE: Perhaps the mst imprtant thing yu can d fr yurself is t be aware f hw yur md and the stress in yur life affect yur pain. This can help prevent lng-term pain and disability. RELATIONSHIP BETWEEN PAIN AND SUFFERING Pain and suffering influence each ther. The mre suffering, the mre pain. The mre pain, the mre suffering. Bth need t be addressed. When yu treat ne yu treat the ther. Pain vs Suffering Treatment fr pain: medicatins, acupuncture, OMT, massage, etc. Treatment fr suffering: trusting relatinship with yur clinician, cgnitive behaviral therapy, emtinal awareness, mindfulness, spiritual cnnectin. Suffering 3rd Therapy Grup Optins Recnditining (strength and supprt) Back pain results in stiffness and lss f strength and range f mtin as the bdy prtects itself against pain. The lnger the pain lasts, the wrse this becmes. Yu then will start t carry yur bdy in a new psitin which is nt nrmal. This can cause yu t feel even mre pain. It is very imprtant t regain flexibility, strength, and t have yur bdy wrk the way it shuld again. Physical Therapy. Physical therapy is an excellent way t regain mvement, strength, flexibility and functin. Research has shwn that yu will be helped mre by a physical therapist designing a prgram fr yur unique needs, than by fllwing a general treatment prgram fr lw back pain. PATIENT HANDOUT 7 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Yga Therapy. Yga means "yke" r unin f mind and bdy. Yga wrks thrugh asanas (bdy pses) and a mindful awareness that yur bdy and mind are ne. A number f randmized cntrlled trials (the gld standard in research) have shwn that yga imprves pain and functin fr peple wh have chrnic lw back pain. Ninety healthy adults with chrnic lw back pain received either a 24- week Iyengar yga therapy class r standard medical care. (Iyengar is a type f yga that places special attentin n bdy psitining). Study participants were evaluated at 12 weeks, 24 weeks and 48 weeks after the start f the class r care. The grup receiving yga was able t d mre, with less pain and depressin than the ther grup. These benefits were seen after 24 weeks. When participants were tested at 48 weeks, the yga grup was still ding better. Anther randmized cntrlled trial f 101 peple with chrnic lw back pain cmpared three types f treatment: 1) a viniyga class (a frm f yga that mdifies psitins accrding t individual needs), 2) an exercise class and 3) an evidence-based back educatin bk. After 12 weeks, peple in the yga grup felt better than thse in the ther tw grups. Lk fr yga classes in yur area that are specifically tailred twards back health. Ask abut the credentials/experience f the leaders. Structured Fitness Classes. Many cmmunities ffer a variety f fitness classes, which can imprve the health f yur back. Lk fr classes such as strengthening the cre, flexibility, spine ball, and pilates. Ask abut the credentials/experience f the class leaders. Lw-cst classes can be fund at cmmunity centers, schl-cmmunity recreatin prgrams, senir centers, and YMCAs. Fitness centers are anther gd surce fr classes. Back Exercises. At the very least, learn sme exercises that yu can d at hme t help with flexibility, mbility and strengthening. An exercise physilgist r persnal trainer can tailr a plan just fr yu. Belw are sme n-line resurces. Patient handut n neck pain frm the McKinley Health Center at the University f Illinis at Urbana-Champaign: http://www.mckinley.illinis.edu/handuts/neck_pain/neck_pain.htm Patient handut n managing chrnic back pain frm the McKinley Health Center at the University f Illinis at Urbana-Champaign: http://www.mckinley.illinis.edu/handuts/manage_chrnic_back/manage_ crhnic_back.htm Vide fr patients demnstrating back exercises frm The Patient Educatin Institute n Medline-Plus: http://www.nlm.nih.gv/medlineplus/tutrials/backexercises/htm/_yes_50_n _0.htm Vide fr patients demnstrating five back stretches and exercises t maintain a healthy back frm SpineUniverse, a website leader in prviding patient and prfessinal health care educatin: http://www.spineuniverse.cm/wellness/exercise/5-back-pain-stretchesexercises-vide. PATIENT HANDOUT 8 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain Feldenkrais Methd Feldenkrais Methd uses mvement, light tuch, and yur imaginatin t imprve physical functining. It can help yu t becme aware f habits f mvement that are pr r restricted. Yu are gently guided t find yur wn best way t mve. The idea is that given enugh chices, yur brain will pt fr the mst efficient way t mve. Feldenkrais Methd des nt strengthen r cnditin yur bdy. Yu can have strng cre strength and yet nt mve efficiently. Feldenkrais will help yu learn t be aware f hw yu mve, where yu hld tensin, and where yu exert unnecessary effrt. There has been little research n using Feldenkrais fr chrnic lw back pain. It has been mst helpful fr peple with lng-term injuries whse bdies may nt be prperly aligned. There are tw ptins fr experiencing Feldenkrais: Awareness Thrugh Mvement Class. These are grup classes led by a Feldenkrais practitiner. The practitiner verbally guides yu thrugh a series f gentle mvements. Yu becme aware f yur habits and rigidities, while yu explre better ways t mve. Functinal Integratin Individual Sessins. The practitiner wrks nen-ne with yu, cmmunicating thrugh gentle tuch, mvement, and wrds. The prcess helps yu becme aware f hw yu are mving and gives yur bdy new infrmatin abut ther ways t mve that may be better fr yu. Feldenkrais practitiners must cmplete 740-800 hurs f training ver a 3 t 4 year perid. Find certified Feldenkrais practitiners and authrized Student Awareness Thrugh Mvement Teachers n the website f the Feldenkrais Guild f Nrth America at: http://www.feldenkrais.cm/practitiners/find/ Fr mre infrmatin n this apprach, see the website f The Feldenkrais Methd f Smatic Educatin: http://www.feldenkrais.cm/methd/frequently_asked_questins/ View a demnstratin f a Feldenkrais Methd practitiner treating lw back pain: http://www.fammed.wisc.edu/urdepartment/media/618/feldenkrais-lw-back-pain. Summary There are a number f ways t treat lw back pain. Imprtant parts f the prcess include: 1) taking an active rle in yur care and 2) wrking with a clinician wh knws yu well. This shuld be smene wh has cmpassin and whm yu trust. When yu have pain, yu need smene t prvide guidance. There is ptential harm frm having t many therapies that fcus n a symptm r bdy part withut having a guide wh sees yu as a whle persn with unique needs. Yur primary care clinician/medical hme can: 1. Listen t yur stry and understand which therapies will likely help yu the mst, 2. Encurage yu t chse ne therapy frm each f the three categries abve, 3. Prvide supprt and regular fllw-up. If yur pain des nt imprve, s/he can refer yu t a spine specialist as needed. PATIENT HANDOUT 9 University f Wiscnsin Integrative Medicine
An Integrative Apprach t Lw Back Pain The infrmatin in this handut is fr general educatin. It is nt meant t be used by a patient alne. Please wrk with yur health care practitiner t use this infrmatin in the best way pssible t prmte yur health. References, if needed, can be fund in the clinician versin f this handut. This handut was created by Charlene Luchterhand MSSW, Integrative Medicine Educatin/Research Crdinatr, adapted frm a handut fr clinicians by David Rakel MD, Assciate Prfessr in Family Medicine and Directr f the Integrative Medicine Prgram, Amy Bauman DO, 3 rd Year Resident, and Charlene Luchterhand. All are in the Department f Family Medicine at the University f Wiscnsin-Madisn Schl f Medicine and Public Health. Date revised: May 1, 2012 Ntes: PATIENT HANDOUT 10 University f Wiscnsin Integrative Medicine