But all of this is really rather puzzling. Many people with back pain have no obvious injuries that show up on an MRI, while MRIs of some pain-free people show what look like serious problems. Problems like extruded disks that used to get you whisked into surgery are now known to be common in healthy people. Big studies of surgery for spinal disk issues show that on average it is no better than a week in bed and some physical therapy. On the other hand I know two people who swear up and down that back surgery transformed their lives, and there are many thousands of such people in America.
So I never know what to make of all this. But I feel sure that one of the biggest problems with back pain is that it is scary. Partly this is physical, because it hurts and feels fundamental in a way that an injured hand or foot does not. It can make your legs go so stiff or wobbly that it is like a pseudo paralysis. Plus there is the background noise, all the people around us crippled by it.
New guidelines from the American College of Physicians recognize the importance of fear in back pain patients:
The new guidelines said that doctors should avoid prescribing opioid painkillers for relief of back pain and suggested that before patients try anti-inflammatories or muscle relaxants, they should try alternative therapies like exercise, acupuncture, massage therapy or yoga. Doctors should reassure their patients that they will get better no matter what treatment they try, the group said. The guidelines also said that steroid injections were not helpful, and neither was acetaminophen, like Tylenol, although other over-the-counter pain relievers like aspirin, naproxen or ibuprofen could provide some relief.We are witnessing a major move away from heroic medicine. Many kinds of surgery are falling out of favor – cardiac bypass, arthroscopic surgery for knee cartilage tears, back surgery for extruded disks – because studies have shown that on average they do little good. Drugs introduced with great fanfare now seem to be only a little better than placebos. Maybe, just maybe, we are acquiring a little medical wisdom, and we will start to cut back on expensive medicine that does little good to focus on what we can achieve.
Dr. Weinstein, who was not an author of the guidelines, said patients have to stay active and wait it out. “Back pain has a natural course that does not require intervention,” he said.
In fact, for most of the people with acute back pain — defined as present for four weeks or less that does not radiate down the leg — there is no need to see a doctor at all, said Dr. Rick Deyo, a spine researcher and professor at the Oregon Health and Science University in Portland, Ore., and an author of the new guidelines.
“For acute back pain, the analogy is to the common cold,” Dr. Deyo said. “It is very common and very annoying when it happens. But most of the time it will not result in anything major or serious. ”