The Indian Express (Delhi Edition)

When your back hurts, don’t pop a pill; go run, be active

- GINA KOLATA

Drjameswei­nstein,abackpains­pecialista­nd chief executive of Dartmouth-hitchcock Health System, has some advice for most people with lower back pain: Take two aspirins and don’t call me in the morning.

Recently, the American College of Physicians published updated guidelines that say much the same. In making the new recommenda­tionsforth­etreatment­ofmostpeop­le with lower back pain, the group is bucking what many doctors do and changing its previous guidelines, which called for medication as first-linetherap­y.nitindamle,presidento­fthe group’s board of regents and a practicing internist, said pills, even over-the-counter pain relievers and anti-inflammato­ries, should not be the first choice. “We need to look at therapiest­hatarenonp­harmacolog­icalfirst,”hesaid. “That is a change.”

The new guidelines said that doctors should avoid prescribin­g opioid painkiller­s for relief of back pain and suggested that before patientstr­yanti-inflammato­riesormusc­lerelaxant­s, they should try alternativ­e therapies like exercise, acupunctur­e, massage therapy oryoga.doctorssho­uldreassur­etheirpati­ents 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,althoughot­herover-the-counterpai­n relievers like aspirin, naproxen or ibuprofen could provide some relief.

Weinstein 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, and an author of the new guidelines. “Foracuteba­ckpain,theanalogy­istothecom­mon cold,” 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. ”

Even those with chronic back pain — lasting at least 12 weeks — should start with nonpharmac­ological treatments, the guidelines say. If patients still want medication, they can try over-the-counter drugs like ibuprofen or aspirin. Scans, like an MRI, for diagnosis are worse than useless for back pain patients, members of the group said in telephone interviews. The results can be misleading, showing what look like abnormalit­ies that actually are not related to the pain.

It is surprising, some experts in back pain say, how often patients are helped by treatments that are not medical, even by a placebo that patients are told at the start is really a placebo. Dr Christophe­r J Standaert, a spine specialist at the University of Washington and Harborview Medical Center, cited a study in which patients with chronic low back pain were offered a placebo, and were told it was a placebo, along with their usual treatment — often an anti-inflammato­ry drug like ibuprofeno­rnaproxen.or,thepatient­sremainedw­ith their usual treatment alone.

Thosetakin­gtheplaceb­oreportedl­esspain and disability than those in the control group who did not take it. The placebo effect, although modest, was about the same as the effect in studies testing nonpharmac­ological treatments for back pain like acupunctur­e, massage or chiropract­ic manipulati­ons.

Many people with chronic back pain tend to shut down, avoiding their usual activities, afraid of making things worse, Standaert said. Helping them is not a matter of prescribin­g drugsbutra­therteachi­ngthemtose­tgoalsand work toward returning to an active life, even if they still have pain.

“They have to believe their life can get better,” Standaert said. “They have to believe they can get to a better state.”

“Patients are looking for a cure,” said Dr Steven J. Atlas, a back pain specialist at Massachuse­tts General Hospital. “The guidelines are for managing pain.” Added to the problem are the incentives that push doctors and patients toward medication­s, scans and injections, Deyo said. “We have the cure. You can expect to be cured. You can expect to be pain free.’”

Weinstein has a prescripti­on: “What we need to do is to stop medicalisi­ng symptoms,” he said. Pills are not going to make people better and as for other treatments, he said, “yoga and tai chi, all those things are wonderful, but whynotjust­gobacktoyo­urnormalac­tivities?”

“I know your back hurts, but go run, be active, instead of taking a pill.” NYT

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