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Low Back Pain: The 3 Recommendations that Your Primary Care Physician Does Not Give You… But you Wish They Had!!!

There have been some serious progressions over the past 10 years with the way the medical field has treated patients with low back pain. The progression has been to go toward PAIN PILLS and INJECTIONS as opposed to physical medicine. What is physical medicine? Well, simply put it is enabling the body to self heal and turn to an active lifestyle to prevent injuries and lessen the effects of disease. Let’s not all get crazy and think that I am saying that medicine is not needed to heal disease or to recovery from injury or illness. I am saying that we (Americans in particular) are looking for the easy way out. Hence, pill pushers!

For example, when we have high blood pressure we take a pill to lessen it. When we have high cholesterol we take a pill to decrease it. The pills taken on a daily basis typically remain part of a daily regimen for life. Every day, get your pill box out, and consume pills. Both morning (AM) and evening (PM). Why? Not only can we reverse these conditions but we can prevent them from ever returning again. It is also true with reversing Type 2 diabetes. But we are conditioned to take pills everyday for the rest of our lives without any kind of instruction on prevention, nutrition, or encouragement to change our lifestyle. Then, this happens. We get a pain in the low of our back with a burning pain running down our leg. We follow up with a primary care physician who prescribes a pill for us to take. What do you think will happen next? The pill will be placed in the pill box for the next 30 days with the rest of your medications. It will be taken daily as prescribed.

So, now what do you think will happen? Well, if the pill has any kind of dependency (this means you can get hooked on it) they will continue to go back to the doctor monthly for a refill on that medication. This will continue until the patient continues to have low back symptoms that persists and they get referred over to a pain management doctor. At this point, your brain is merely seeking a drug fix. You have no idea if your back still hurts only that your BRAIN desires a pharmaceutical remedy. Let that digest for a moment! Think about your current daily pill regimen. This is how our society has been kicked into relying on pills to cure their problems.

I do have research to back up what I am saying! Although I see this far too often in the clinic, the research has been forthcoming with how the changes in management of low back pain have been evolving. Here is an article about a very disappointing statistic with the current health care system:

Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary care referral of patients with low back pain to physical therapy: impact on future health care utilization and costs. Spine 37(25): 2114-2121

The above referenced article took data on 30,000 patients who were a new visit to their primary care physician for low back pain. Only 7% of those patients received a referral for physical therapy services. The other 93% received medication and were either sent home with nothing, a referral to a pain management doctor, or orthopedic surgeon. ONLY 7% were referred to physical therapy (PT)!! The article further looks into the timing of the patient receiving PT. If the patient was referred to therapy within 14 days of the initial onset of symptoms there was a decreased risk of needing advanced imaging (MRI), additional physician visits, injections, and/or surgery.

Now, I get it that many people do not really know what exactly they should do when they hurt their low back. People get nervous and the immediate reaction is to want to reduce the pain. At first, one thinks that medication will reduce the pain and the problem will go away. However, if we use logic and ask the question WHY does my back hurt we might be able to prevent an episode ever coming back again. A primary care physician does not have the time or training to determine WHY someone hurt their back. They have time to dispense medication.

So, should we be training our primary care physicians to refer to therapy? Well, they are bombarded daily with changing medications and people who are critical that need close medical supervision to manage their disease. Low back pain is not a critical disease. It is a symptom of a problem. Usually a problem that we bring on ourselves by lifting incorrectly, lifting too heavy, or by poor sitting/standing postures. A problem that is resolve by a physical therapist. The reason I am writing this blog is not for education of the medical community. It is for the layperson who needs an option other than pain pills or injection. Worse off yet, low back surgery.

Are the drugs you are taking working for you or just “tricking” your mind into believing that if I take this magic little pill the pain will subside for about 4 hours. Then, take one again for a few more hours. Rinse and repeat.

Let us talk about those pills that you are taking:

March 23, 2017 the New England Journal of Medicine released an article named: “Trial of Pregabalin for Acute and Chronic Sciatica.” Pregabalin is known as Lyrica in the Pharmaceutical market. It is marketed for neuropathic pain and can help in certain cases. It has recently become very popular and see a lot of patients taking high doses of this medicine. Neuropathic pain is damage to the nerve fibers themselves. This breakdown of nerve fibers sends incorrect pain signals back to your brain in the form of pain.

Now, back to the research paper… Over 200 people were included in the study and were randomly split into a group that received Lyrica and the other received a placebo (basically sugar pill or a fake pill). The researchers checked on the symptoms of sciatica in both groups of patients at 8 weeks and 52 weeks. There was no difference between groups at 8 and 52 weeks. So they were measuring the intensity of pain in the leg for all participants. The leg pain intensity did not vary enough between groups to be statistically significant. What the Lyrica group did receive was a myriad of adverse effects including dizziness.

February 14, 2017 the Annals of Internal Medicine published a report called “Noninvasive Treatments for Acute, Subacute, and Acute Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. They basically looked at all published research on the most affective treatments for the various phases of low back pain. Here are their top 3 recommendations:

  1. Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation)
  2. For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate- quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation)
  3. In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence)

So, these recommendations are great! Stay away from pain pills and use muscle relaxers if necessary. Get treatment in the form of acupuncture, moist heat, massage, and exercise! What does that sound like? Physical Therapy, right?

Look, I am definitely a proponent of physical therapy services for any and all episodes of low back pain. This is going to be the start of YOUR education on what to do if you do have low back pain.

Start with this ebook and ask questions. The medical field is notorious for confusion and making people feel helpless. The only thing worse is the legal field! (Yea! I said it!) Below is a link to a free report on how to reduce low back pain. There is a bonus section that includes some beginner exercises to get you on the path to decreasing low back pain.

(If it does not direct you, copy and paste it in your browser)

This has been a lot of information about the treatment of how low back pain is currently being managed. I hope this has not been a confusing read. I do hope that it makes you think about the options that you DO have as a patient in order to reduce your low back pain effectively. I love being a physical therapist and helping people heal with the skills I have learned over the span of 10 years.

If you would like more information on how to reduce low back pain for yourself or for a loved one please contact me. I am happy to answer any questions that I can, however, nothing will help you faster than an appropriate evaluation by a qualified physical therapist.

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Optimal Physical Therapist, Mike Russell smiling portraitMike Russell is a graduate from the University of Nevada, Las Vegas department of physical therapy in 2007. Since that time, his research interests have included balance rehabilitation for athletes and the aging population, shoulder pain and the overhead throwing athlete, foot volumetrics related to running versus walking, lower extremity, pain with running and run related injuries. Dr. Russell has been assisting runners, triathletes, and cyclist to help them return to competition with an emphasis on “prehabilitation.” This term is the type of work and rehabilitation that athletes need to engage in to prevent injuries. Dr. Russell has extensive training in the use of dry needling techniques to help alleviate aches and pains faster with less time away from activities that people love. Clients of Dr. Russell enjoy the ability to stay active, avoid the use of pills or pain medication, and avoid costly surgery and procedures.
Dr. Russell can be reached at: mike@optimalptlv.com or 702-768-8050

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