If you have pain in the lower portion of your back, or if you have had such discomfort at some time, you are not alone.  Up to 80% of adults in the US have acute low back pain at some time in their lifetimes.

Dr. Richard Deyo, an internist on the faculty at the University of Washington in Seattle, investigated this important condition and published seminal papers on back pain in the latter part of the 20th century.  He documented that low back pain, after upper respiratory complaints, accounts for the second most common reason for symptom related visits to physicians.  Back pain is also the most common cause of work related disability, and the most expensive, especially when the loss in work productivity is considered.

Definition 

Acute lower back pain (emphasis on acute–this article does not address chronic pain) may be sharp or achy and it may spread to the buttock or down the back of a leg, in which case it is called sciatica.  It may come on for no discernible reason, or after activities such as lifting improperly or twisting.  

What To Do About It

When I was a young doctor in the late 70s and early 80s, the conventional wisdom for treatment of low back pain was bed rest for three days, with mild analgesia such as aspirin or acetaminophen (Tylenol) as needed.  With solid clinical research and extensive review of the medical literature, Dr. Deyo debunked this intervention.  In fact, he laid waste to a lot of the common interventions, including chiropractic manipulation, physical therapy for acute episodes of back pain, acupuncture,  traction, injections, electrical nerve stimulation, massage and surgery.  Each of these treatment modalities appears to have some advantage, mostly because low back pain is self-limited.  90% of patients so afflicted recover within two weeks no matter what they do.

He also highlighted the uselessness of x-rays in acute situations, noting that x-rays, even fancy ones like CT scans, correlate poorly with symptoms.  Many people with no back complaints have radiographic evidence of severe spinal problems (e.g., slipped disks), while some patients with significant back pain have pristine x-rays.

Because the natural history of low back pain is quite favorable, Deyo found that no specific diagnostic or therapeutic interventions should be undertaken in the acute phase of discomfort.  Patients can be reassured with the knowledge of the benign nature of the pain and can be allowed to pursue activity as tolerated.  Of course, recalcitrant cases justify further investigation and treatment, even to the point of surgical intervention in a small number of cases.  Importantly, “red flag” cases of back pain would require prompt attention.  For instance, a patient who carries the diagnosis of cancer, especially one that is known to spread to bone (e.g., lung, breast, kidney, prostate), should seek care immediately.

Recent Research

When I read Dr. Deyo’s articles on back pain years ago, I thought his research was definitive.  Nevertheless, researchers continue to seek ways to effectively treat this important condition.  Most recently, researchers published a paper (the impetus for this article) that reported a small advantage to different forms of physical therapy for chronic back pain of less than 12 weeks duration.  This study did not address acute back pain and showed minor improvement at three months. The research was flawed, but did show a small reduction in spinal disability three months after the intervention; this advantage disappeared at one year.

Costs (and Waste)

There is an important wrinkle to the back pain issue.  And that is cost, especially given the mostly useless diagnostic and therapeutic interventions for back pain that are common in our medical system.  In 2016, the American healthcare system spent $134.5 billion on interventions for low back pain and neck pain (these are not broken out in the data). This is a little over four percent of the total amount spent on healthcare for that year ($3.3 trillion).  And a large portion of that expense was from questionably useful surgical interventions: back surgery rates are 40% higher in the US compared to any other country, and five times the amount in England and Scotland.  Some studies show that the amount of surgery correlates highly with the number of neurosurgeons and orthopedic surgeons available.  Only the most naive observer would think there is not a proprietary aspect to decision making in the care of patients with back pain.   

Disclaimer

I am making no recommendations regarding how readers should go about dealing with back pain.  I am simply reporting what is in the medical literature.  But I can say that maintaining a healthy weight and being active can go a long way in preventing back problems.  And here is a cost-free preventive measure: bending your knees when lifting something off the floor.