When it comes to back pain, time is an underused treatment

The doctor at the summer camp I attended as a kid believed that calamine lotion and time cured just about anything that ailed campers — and he was right. Time still heals most wounds, but patience is a tough sell to people whose visits to my office often involve taking off work or getting a babysitter, fighting traffic, and shelling out for parking and insurance co-pays.

After all that, time doesn’t seem like a satisfying prescription. Still, an article published in JAMA Internal Medicine by researchers at Harvard Medical school and featured in Boston Magazine reveals that when it comes to back pain, time is an underused treatment.

Low back pain is among the most common reasons people visit primary care doctors for non-routine care (cough tops the list). The long hours we spend commuting and sitting at computers contribute to back pain, as does obesity and “weekend warrior” syndrome — when usually sedentary people paint a house, rake a yard, or take up a sport or exercise for which they are poorly conditioned. About 40% of adults will have low back pain at some point.

Generations ago, low back pain was called “lumbago” and treated with rest, heat, ice, massage, and various topical treatments or plasters. There’s still little evidence that much more than these are needed, in most cases. Anti-inflammatories such as ibuprofen (Advil) are helpful, as well as acetaminophen (Tylenol). Gentle yoga or stretching are also good. As the authors of the JAMA study, who reviewed 24,000 cases of acute back pain, discovered, time heals not all, but most back pain.

But, as I said, time is a tough sell, especially when there are now so many options, beyond plasters, to diagnose and treat back pain. Patients often request and doctors often recommend x-rays, MRIs, epidural injections, narcotics, referral to specialists, and spine surgery. These treatments are often expensive, invasive and, in the long run, no more effective than simpler approaches. Over-prescription of narcotics for back pain is particularly dangerous, as it is frequently the first step on the road to addiction.

In a small minority of cases, low back pain is a sign of a serious condition. Back pain accompanied by fever, blood in the urine, weakness or numbness in the legs, or other unusual symptoms should be evaluated by a doctor. Patience isn’t the right treatment in all cases of back pain. (When I arrived at the camp infirmary vomiting, and with pain in my right lower abdomen, the doctor prescribed neither calamine lotion nor time — he took me to a hospital to get my appendix out).

Uncomfortable, but less ominous episodes of back pain can also be evaluated, but a prescription of Advil, rest, yoga, and time shouldn’t feel like “doing nothing.” Sometimes “nothing” is the best treatment.

Suzanne Koven is an internal medicine physician and a Boston Globe columnist.  She blogs at In Practice at Boston.com, where this article originally appeared. She is the author of Say Hello To A Better Body: Weight Loss and Fitness For Women Over 50.

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  • John C. Key MD

    I love physical therapy, recommend it a lot, and think there is much wisdom in what you say….BUT–not all patients want it, some insurers won’t pay for it, and sometimes the PT Clinic says, “Sure we can see him for an evaluation in three (3) weeks!” So before putting a pipe bomb under the primary care docs, remember that there are often extenuating circumstances other than stupidity and lack of training.

  • Suzi Q 38

    “…..Back pain accompanied by fever, blood in the urine, weakness or numbness in the legs, or other unusual symptoms should be evaluated by a doctor…..”
    No kidding. My numbness in the legs, hands and feet were dismissed by my PCP as pre-diabetes.
    Since my symptoms came on a few months after my hysterectomy, I thought it was related. Maybe, maybe not.
    At any rate, my symptoms slowly and insidiously escalated, until I could barely walk. My PCP did not know what else it could be, my Gyn oncologist was “lost,” and his friend the neurologist was “out to lunch” mentally as he was moving to our state from another state and had to rent an apartment and ultimately buy a house. I should have “dumped” him (the neurologist) but I didn’t know what I had either. My NP friend said that my problem was that I visually looked fine.
    Anyway, I had severe spinal stenosis in my cervical spine. I was getting worse by each day.

    I needed a few pain meds, but I had some left over from my hysterectomy a year and a half prior. I used the Norco sparingly (1/2 tablet once every two weeks) plus the usual OTC analgesics, alternating days.

    Any way, the PT’s were a ripoff too.
    I would go in and they would work on me maybe 15 minutes. Next they would have me do all these easy exercises on my own. After 30 minutes total of being there, they handed me a bag of ice. I am fairly bright, so I finally told them that if that was going to be the norm, I could do that at the gym or at home.

    They withheld my bills for several months.
    When I finally received a bill 3 months later, I realized that they charged my PPO insurance about $250.00-$300.00 each time. My co-pay was about $30.00 each time. Sadly, I had a hunch this would be the case.
    I switched rehab centers and I got similar treatment, so I eventually stopped going. It did not help my pain.

    I now have a different neurologist and she put me on 25 mg of Elavil and slowly had me titrate the amount up 1/2 a pill a week. I got great relief at about 50 mg so I stopped increasing it. I finally got the sleep I needed, but I have gained 10 pounds……such is life. Elavil is a really old drug, generic and cheap. I no longer need the Norco, and all the other analgesics. I would love it if I could find a really good PT specialist instead, but I admit I have finally given up hope on that.

    Anyway, I believe that rehab is only as good as each individual physical therapist. I am still looking for a really good one.

    • DoubtfulGuest

      Suzi Q 38, have you seen a physical medicine doctor or do you have the option to see one? I think that’s the same as a physiatrist but not sure. I wonder if they could help.

      • Suzi Q 38

        Thank you.
        What is a physical medicine doctor?

        • DoubtfulGuest

          I’ve never been to one…Becky is more knowledgeable there. Same as a physiatrist, she says. At my hospital they are called physical medicine doctors. It’s my understanding they help with PT kinds of things but more specialized for different kinds of diseases. I only have experience with muscle problems, not nerve damage. So, I don’t want to steer you wrong. But I want to make sure you have every option to help with your trouble walking, etc. I think they do comprehensive gait evaluations and look at alignment problems, for example.

    • querywoman

      Many drugs have various uses. Elavil is often used to pain. I took it for migraines in my early 20s.
      I visited my father once in the VA during some stay for heart or some other somesuch, the kind of stuff they like to treat.
      My father repeatedly complained of back pain, and got nowhere. I could see that he was depressed, and was suffering discrimination for being male and depressed.
      However, he was stooped from spine degeneration. He’d a lifetime of hard work. I think it may have been genetic, also.
      He saw a description of depression in Reader’s Digest that fit him to a tee. He brought it to their attention and got locked up in the psych ward a few days.
      Whatever antidepressant they put him on also fixed his back pain, in spite of his physical disability.
      The reason I bring this up is that there are many options other than narcotics for pain and this or that expensive new drug.
      It’s good the the Elavil is working for you. I wouldn’t worry too much about a ten pound weight gain, but maybe you can eventually get off it.

      • Suzi Q 38

        Thanks, QW.
        My daughter says the same thing, and I remember promoting Sinequan (doxipin) for pain and sleep as well as depression. Elavil is in the same class of drugs, which are now generic and have been for years.

        • querywoman

          I two 10mg doxepin last night and conked out to aid my post-pneumonia recovery. It’s appropriate for me because of the antihistamine effect.

          I gather the Elavil is new to your cocktail of drugs and it is working for you. So it’s a ridiculously simple answer that should have been tried ages ago.
          Makes you sleep good, doesn’t it?
          I assure you that you hysterectomy surgeon thought you were “depressed” after the surgery. So why didn’t he try elavil?
          Depression is such a bull dinky not specific diagnosis. I told a psychiatrist that I got noise-sensitive during my menstrual period. She described it as “depressed.” Wrong!
          Yet, she was the one who suggested I had a mild version of Asperger’s Syndrome. I researched it and agreed.
          A family doctor put me on clonidine for the Asperger’s, which helped the environmental sensitivities. The psychiatrist didn’t even know about using clonidine for Asperger’s.
          Clonidine and doxepin are dirt cheap, and excellent drugs for me.

  • Lisa

    mmm, where to start…I tend to agree with the author, but there are drawbacks to ‘doing nothing’

    I had low back pain, beginning in my mid thirties to my mid forties. It was severe. At times, I would be unable to walk. It affected my life in major ways. I became less active as many activities would cause intense pain. I had x-rays which didn’t reveal anything significant and I was sent to PT several times over the years. PT was somewhat helpful. Anti inflamatories didn’t help and I was never offered stronger pain medication.

    When I was in my mid forties, I had a large uterine fibroid removed. After the surgery, I noticed my back didn’t bother me and I have not had significant back pain sense then.

    My conclusions after this experience is that while many ailments may improve with time or are self-limiting, a proper diagnosis should be obtained, especially if symptoms don’t clear up in a reasable amount of time. I resent the fact my doctor’s were dismissive of my back pain. I also blame myself for being passive, for accepting my doctor’s diagnosis of a ‘strained muscle.’

  • querywoman

    Low back pain is one of those very strange problems, indeed. My mother went to an ER with my younger brother when she had terrible back pain. She finally walked out after many hours of waiting.
    Next morning, she popped a couple of Tylenol, and both she and my brother were amazed at how much better she felt.
    But it’s not that easy for a lot of people.
    The problem come when docs don’t take it seriously.

    • Suzi Q 38

      So true.
      The Tylenol and other OTC analgesics work for me too.
      I try very hard not to take the Norco. I haven’t taken one in about 3 months.

  • DoubtfulGuest

    Thanks, Becky. I know there are some good ones at the hospital I go to. I have not seen one myself yet, and I’ve been confused by the different names. I am glad you found one who treats you well and has experience with your disease. That must be incredibly difficult to deal with.

  • DoubtfulGuest

    I have a lot of respect for PTs and have had some really good ones. I’ve also had a few with tunnel vision who were quick to assume malingering if something didn’t add up. In my late teens, I saw one for a low back injury (from lifting a heavy box, getting ready to move back to the dorms). She was the first medical person ever to note that I seemed to have something weird going on, and possibly much worse. She did all those muscle strength tests and I didn’t do that well. She suggested I ask my doctor to be tested for JRA. It turned out not to be that. It’s a metabolic myopathy that unfortunately didn’t get diagnosed for another ~14 years. But she noticed it was something serious, even though MDs were blowing off my other symptoms. The back injury was just the tip of the iceberg. I can’t recall her name or office location, otherwise I’d send a thank you note.

  • Suzi Q 38

    Not yet.
    They claim to have this experience, but I am not so sure.
    Some are simple exercises that are easy to do at home.
    Other treatment I had involved a tens unit.
    They would put the tens unit wires and pads on my spine and them turn on the electricity, LOL. I finally asked if I could buy one. I bought one for under $100.00, and my insurance agreed to pay for it.

  • DoubtfulGuest

    Thanks for stepping in, Becky. Wow, you have had a bad time. I’m glad he’s taking good care of you.

  • Suzi Q 38

    Thank you!
    I will check it out.

    • Becky

      Obviously, if treatment is recommended, it would be different than what I get. I also happen to have an amazing doctor.

  • medicontheedge

    Time??? “Ain’t nobody got time for that!”
    Today’s consumers of healthcare want their care delivered like their fast food: quick, cheap, and with little effort on their part. Hell, medical business markets this. way.

  • DoubtfulGuest

    That would be really hard, Becky. I know very little about your disease…does it make you more susceptible to complications? Or have you just been unlucky? Do they tend to blow you off when you report problems? I know the difficulties of having a zebra, although mine is, shall we say, firmly on a leash for the time being. Yours sounds worse, and I’d think/hope they should take you seriously given what you have going on. You’re a bit younger than me, too. You ought to be able to enjoy that instead of always being in pain. I’m with you on defensive medicine… Makes it hard to trust doctors. We rarely know what we’re getting into with them, then we find out about all these external factors that we didn’t intentionally sign up for…

  • DoubtfulGuest

    Becky – That sounds just awful. I have never dealt with either of those things. Is it risky in any way to give the colonoscopy prep med in the hospital just in case you were right? (and you were). I know the kind of stuff you’re talking about. I think it’s really inexpensive? and I can’t understand why they didn’t believe you. How did they fix the dural leak or did it eventually close on its own? That sounds so painful, I am sorry you went through that. Over on the ‘patient profiling’ post I attempted to get some discussion going about instances that doctors don’t revise their initial hypothesis when new information comes in. —–> ***crickets chirping***

    :/

  • Suzi Q 38

    Yes.
    Thank you for asking.
    I have a neurosurgeon who saw me a year ago and performed cervical neck surgery on me to stop the progression of my condition.
    Unfortunately, it did not give me back what I lost while under the care of my doctors, who did not care or listen to my complaints.

    I am still living with substantial pain, even though I feel better.

    I am just lucky that the pain is controlled by an old antidepressant (amitriptyline), rather than an opioid.