ON HAVING A ‘BAD BACK’


Ever heard someone saying they have a ‘bad back’? That’s a rhetorical question because ‘bad backs’ are responsible not only for enormous suffering but also have a huge impact on the economy.

In 1950 backache accounted for 1.5 million days of work last but by 1995 this had risen to 115 million (sic) days lost. What on earth are we doing differently? Sitting too long? Working harder? More stressed? Less robust? Less willing to work while in pain?

The very fact that there is such a condition as a ‘bad back’ tells us that we know very little about backs and back pain. Ever heard of a ‘bad heart’, ‘bad brain’ or ‘bad eye’?

Tests can sometimes help by showing a severely prolapsed disc or other very obvious damage but people with back pain can have abnormal MRI results and people in debilitating pain can have normal X-ray and MRI results.

Without accurate diagnoses, medical treatment tends to be speculative. Surgery, micro-surgery, steroid injections, manipulation, pain killers, alternatives such as acupuncture and osteopathy – all claim results but no one form of treatment can claim uniformly good results for back pain.

The problem may be that helping back pain may be something that often requires great commitment by the patient. Our bodies are supported not only by our backs but also by a host of abdominal muscles including the very important oblique muscles of the abdomen. Strengthening these muscles by a carefully structure exercise programme can be spectacularly successful and yet I see so many patients who have not been taught and encouraged how to do this.

Is  this  because programmes to strengthen the abdominal muscles and produce core stability are ‘boring’ and are not easily packaged or sold in bottles.

A pity – because they really work.

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Comments

Thanks Dr K. I have a bad back and have had for years. It seems that if its not sorted out the bad bits relocate themselves to compensate for the weakest link. Abdominal strengthening is definitely the best remedy.

Doc, you have provided a very good summary overview here!

If there was ever a quackery hunting ground in medicine, this area is virtually unsurpassed.

The back industry is gigantic, as we all know. It is not taught well in medical curricula, and most doctors do not even know how to take a good history and properly examine a back. This is where the big mistakes occur. MRI’s enter the picture too early (good for radiologists; poor diagnostic value), injections (e.g., epidural steroids, good for anesthesiologists) are liberally overused (there is no good literature supporting routine use), and then you have the professions ranging from physiotherapy to chiropractic, acupuncturists to self-professed experts (often with late-hour infomercials) soaking up the patient’s resources.

Amazingly, after enduring all this stuff, the back problem remains poorly defined (‘bad back’ is almost hilarious).
Back surgery often enters the picture too early and inappropriately (good for surgeons). Medications are consumed with abandon (good for pharmacies and drug companies) and sufferers often become dependent on narcotic analgesics.
Most chronic phases are identified if there is no/little improvement in ~12 weeks. These cases can be trenchant, and must be identified early, if possible. Yes, this implies that the majority of patients actually do well without any intervention (other than conservative care, consisting of diagnosis, appropriate physiotherapy and strengthening/stabilization exercises). A wrong/no diagnosis will fail to properly direct the type of conservative intervention required (e.g., pelvic girdle dysfunction can be worsened by routine physiotherapy, if not corrected first via osteopathic maneuvers). It will also cause some patients to unwittingly cross the 12 week line and end up in the hands of a ‘surgical carpenter’, often ending up with ‘failed back syndrome’.

So how does one avoid falling into the potential vortex of hell? Diagnosis first, treatment second. Prevention is also essential and consists of learning how to not move in such a way that one’s back absorbs a disproportionate load (e.g., bending knees when lifting heavy objects, regular stretching and abdominal stabilization).

Unfortunately, it is in our nature to take good health for granted. We often fail to recognize that health (body, mind, spirit) is priceless and, without question, the one thing that cannot be sacrificed upon the altar of bad habits. Chronic back pain can rock one’s world beyond recognition. I know this, having been through it myself.

Regards,
Ruth

Dear Dr Kaplan – Wouldn’t it be a good idea to begin in youth to teach children how to bend knees to pick up items off the floor and give calesthnics that strengthen abdominal muscles? Pilates and yoga have become popular in every country. Do more women than men take these classes for mindfulness and body health? I always feel that lifestyle changes are the best place to begin when it comes to our health and attempt to eliminate pain. Blessings, Debby

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