You're worn down by intermittent back pain. It's an unpredictable beast. It can come on so strongly you cannot walk, or sit.
At least you think you can't (but read on).
In desperation, you consider surgery — but this is not always a good move.
The evidence of benefit from surgery is weak at best, as a recent Lancet series on lower back pain found.
Despite this, plenty of people are still going under the knife. Lumbar spine surgery rates are doubling roughly every 10 years, according to University of NSW professor of orthopaedic surgery Ian Harris.
And, he said, the operations are getting more complex, and therefore more risky.
"What we are seeing is an increase in complex surgery over simple surgery, in particular fusions, in particular multilevel fusions."
There are however, cheaper, more effective ways to deal with back pain. We asked the experts what works — and what doesn't.
Get Moving
Yes, even if it hurts. Once you have the all clear from a doctor or physiotherapist, you are safe to move.
Developments in neuroscience indicate that the brain creates pain as a mechanism to protect us.
In the case of chronic pain, the pain system gets more sensitive. Our body learns pain — and so we feel it more acutely.
When it comes to chronic pain, the brain is being overly cautious. Pain is increased by fear of re-injury and a whole host of other factors. And so, over time, our body creates a bigger than necessary pain buffer zone.
But you can still move — and exercise — within that pain buffer zone, without causing tissue damage, according to University of South Australia professor of clinical neurosciences Lorimer Moseley, who is at the forefront of Australia's world-leading brain and pain research.
"If we can appreciate that pain is a protective device, not a measure of tissue damage, if we can communicate that to people, then we change the game," Professor Moseley said.
When people realise they are safe to move, they can start to get better, he said.
Associate Professor Mark Hancock, a physiotherapist researching lower back pain at Macquarie University, agrees.
"If people stop moving they get weaker and stiffer and it often causes more harm. Moving into a little bit of pain is appropriate," he said.
Move how?
There's a plethora of activities promising to be good for backs, from Pilates to the Alexander Technique, to half a dozen forms of yoga.
Associate Professor Hancock said although there is no strong evidence that one type of exercise is superior to another, most exercise is beneficial.
"There is no evidence that any specific exercise is dangerous if done appropriately or by people who are ready for it," he said.
But if after an acute onset of back pain there is not improvement over two weeks, perhaps seek advice from a physiotherapist.
"A good clinician will help find the most appropriate exercise for the person," he said.
"If muscles are weak around the spine then it's strength exercise."
If there are coordination or movement problems, it could be a different exercise.
A patient's preferences are important, too. There's no point taking up swimming if you don't like water.
And movement has an added bonus. Most back pain is recurrent, but exercise has an important preventative role.
"It's a good news story," Associate Professor Hancock said.
"There's evidence that exercise reduces the rate of recurrence by 50 per cent. That's a good reduction. Not a lot of medical treatments are that effective."
US journalist and author of Crooked: Outwitting the Back Pain Industry and Getting on the Road to Recovery, Cathryn Jakobson Ramin, said her own back has responded to some fairly simple intervention.
Now 61, she had suffered back pain since the age of 16, but these days is mostly free of it.
"What I discovered is I had a very weak upper body," she said.
"I had a lot of fear, which was taking its toll. I'd had enough pain that I was afraid to do anything that might cause more. I realised I had gluteal amnesia. My butt had fallen asleep.
"Once I began to do the exercises that recruited those muscles, and recruited all the pelvic muscles, things got better and they got better fast."
Scans & X-Rays
Seeing an image of your spine has to help explain the cause of the pain, doesn't it?
No, not usually, according to Associate Professor Hancock, who was one of the 30 international authors who worked on the Lancet back pain series.
He and his co-authors found widespread overuse of imaging for back pain.
The reason a picture of a bulged disc, for example, doesn't tell the whole story, is that everyone's spines change over time — and two people can have exactly the same imaging findings, but one of them will feel no pain at all.
Associate Professor Hancock acknowledges doctors are under pressure from patients who want to see what's going on in their spine.
But he said scans for simple lower back pain should not be subsidised by our health system, as they are costing far too much, with questionable usefulness.
Cortisone Injections
Often offered as the panacea, the use of cortisone injections has "doubled, perhaps tripled, over a short period of time", Associate Professor Hancock said.
They have become a very common intervention for people with sciatica.
The Lancet researchers pulled together all the available literature on the injections — and again, there was little justification for cortisone injections.
"The best estimate we have from previous studies is that corticosteroid injections reduce sciatica (leg pain associated with back pain) by only five points on a 100-point scale compared to placebo in the short term, with no long term benefit," Associate Professor Hancock said.
"So it's a very small difference."
No surgery … ever?
"You can never consider surgery as your best option for ordinary low back pain. because an intact spine is always better than a surgically altered spine," said Ms Ramin, who is adamant on this point.
For her book, Ms Ramin researched what she calls the "back pain industry", and its many surgical trends over the decades.
Problems emerged with each, and new techniques would take their place, but rarely with adequate evidence, she said.
There are exceptions where spinal surgery may be warranted — for trauma, tumour, or neurological deficit from instability or displacement of the vertebrae.
But Professor Harris — an orthopaedic surgeon himself, who wrote the book Surgery, The Ultimate Placebo — agrees that for most back pain, surgery is not the answer.
"For patients with typical degenerative changes in the spine and chronic low back pain without a significant neurological problem, I would not advise spine surgery in any situation," he said.
"It is expensive and increases the risk of harm and there is no high-level evidence of a benefit."
In the workers' compensation system, the impact is dire, he said.
"We have previously shown that the results of this surgery in this group of patients is poor, with only 3 per cent returning to pre-injury duties and about 89 per cent still taking major narcotics for pain relief at 24 months post-surgery," Professor Harris said.
"The cost to the workers compensation system for this surgery is about $100,000 per procedure."
Stay off the drugs
Back pain is the main reason people use opioids over a long period of time, according to the Lancet authors.
However, the addictive harm of opioids has been well documented.
Associate Professor Hancock said a short stint on anti-inflammatories may be helpful.
"The important thing is not taking meds for a long period," he said.
"If a short period of anti-inflammatories helps get the person moving, then that's appropriate."
With opioids, it's a different story.
"But with opioids we know that even very short periods of use increase the risk of dependence. Try to avoid them in almost all cases," he said.
Rethink your pain
Sometimes the very language we use to describe pain — "feels like a knife" and "there's something burning in there" — contributes to the experience of pain. Drug advertising urges us to fight pain, attack it, and see it as an enemy.
Instead, the Pain Revolution movement, led by Professor Moseley, wants people to understand what the science indicates — that pain is a friend that protects our tissues when they need to heal.
But it can get over-protective, because the brain is responding to all kinds of influences.
Professor Moseley said being aware of that has many benefits. The change of outlook — letting go of the fear — allows people to gradually increase what movement they can do. We need to retrain our pain system — body and brain.
As well, varied and new experiences, of sight, smell, touch and creativity may reorient neural pathways and be helpful.
Find the right clinician
How do you make sure you're on the path outlined above? It might not be easy, but try to find a GP, physiotherapist or chiropractor who is across the current evidence.
There's a strong view among pain researchers that not nearly enough is taught in medical school, or in other clinical courses, about the complexity of pain and the potential to influence it.
And when it comes to the lower back, many practitioners are not keeping up with the guidelines, Associate Professor Hancock said. The old days of ordering bed rest are long gone, yet some clinicians still advise rest.
"If the clinician is recommending MRIs, investigations and injections, that should be a red flag to you," Associate Professor Hancock said.
"If a clinician says see me three or four times a week for hot packs and massage, that's also not good evidence-based care. It's passive. You're not taking responsibility.
"The focus should be on you being given the skills and knowledge to self-manage in safe and simple ways."
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