At some point in our lives, some four out of five of us will suffer from chronic back pain -- and wonder what we can do to make it go away. It turns out that having a high-tech imaging test to diagnose the cause may do more harm than good, according to new guidelines released Monday from the American College of Physicians.
"Routine imaging does not seem to improve clinical outcomes and exposes patients to unnecessary harms," write the guideline authors. They cite statistics showing that despite increased spending on low back pain, we don't report feeling any better and actually may be handling our pain worse than in the past.
"When it comes to dealing with back pain, more isn't necessarily better," says Dr. Steven Atlas, an internist at Massachusetts General Hospital who is familiar with the new guidelines. "Patients could benefit from having less."
The guidelines recommend an X-ray, CT scan, or MRI only for those with new back pain who are suspected of having a spinal tumor or infection, major traumatic injury from a fall or car accident, a spinal fracture from severe osteoporosis, or signs of a rare condition, called cauda equina syndrome, that causes nerve damage.
The vast majority of back pain sufferers should wait at least a month to see if their pain abates before considering having an imaging test.
What's the harm in having one earlier? First, you'll get a small dose of radiation from CT scans and X-rays (though not MRI's), and recent research suggests that radiation from imaging tests accumulates over a lifetime, contributing to cancer risk. Second, imaging tests often show evidence of arthritis or spinal disk abnormalities that doctors assume need to be treated with surgery.
Sometimes the problem found on the imaging test is the culprit of the pain, sometimes not. But most of the time, the body will heal itself on its own without surgery. "It's hard for physicians to sit on these results and not do something to fix the problem," Atlas says. It's hard, too, for those in pain to hear the words: just give it time.
"We think our backs are never supposed to hurt but that's not true," says Atlas who recalls having chronic back problems from lugging his kids around when they were young. Now, years later, he has occasional twinges, probably, he says, from arthritis setting in.
He tries to explain all this to his patients when they come to him with back problems. "It's very rare that I need a diagnostic imaging test to tell me what treatment to recommend," Atlas says. Usually he relies on taking a thorough patient history and a physical exam.
Most often, Atlas recommends that his patients rely on over-the-counter pain relievers like ibuprofen or acetaminophen to help them "muddle through" while their body heals.
Several weeks of physical therapy -- which usually involves stretching and muscle building exercises -- can also help relieve the pain, though therapists may need to experiment with different regimens, Atlas says, to see which one works best to relieve discomfort.
"It's tough to find good evidence that any of these actually speed the healing process," he adds. But they might be worth a try considering they're nearly risk-free.
Simply walking, though, may be the best thing you can do to help relieve the pain, while lying in bed under the covers may be the worst.
So when is it smart to have an imaging test for chronic back pain?
"It may be a good time if your pain persists for more than a few months, and it's impacting your life, not allowing you to fully function," says Atlas. Say, you're in pain every time you sit and you have a desk job or you can't lift anything over 5 pounds and you're a construction worker.
You should also be at the point where you're willing to consider surgery. It could help speed the healing process in those who, for example, have a pinched nerve due to sciatica or severe spinal stenosis, which tends to afflict those over 65.
But surgery, too, usually causes weeks of recovery pain. Atlas says most people bounce back from sciatica or disk surgery in about a month, but recovery from spinal stenosis often takes at least three months. What's more, about 5 percent of those who have surgery still wind up with chronic back pain.
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