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Treating Lower Back Pain Without Opioids

Hello I’m Dr. Paul Christo Associate
Professor in Academic Pain Medicine. I also host Aches & Gains radio talk
show on Sirius XM. We’re here to explore alternative treatments for acute
non-specific low back pain. Although pharmacologic management can often provide prompt relief to patients suffering with back pain, there are other
options. Opiate overdose is a growing epidemic, learning to detect and prevent
the unnecessary use and abuse of opioids, and improving the way we prescribe them,
can greatly reduce the number of patients who use and misuse these
medications. The American College of Physicians offers guidelines, which
strongly suggest the use of alternative therapies including acupuncture, thermal
therapy, massage, physical therapy, and chiropractic treatment as first-line
options. These alternatives may allow millions of Americans to maintain an
elevated quality of life while avoiding the risk of addiction. One of the many
first-line alternatives to pharmacological treatment is acupuncture.
For over 2,500 years, acupuncture has been used to maintain wellness and treat
pain. This time-honored therapy uses fine needles inserted into selected points on
the skin to release blockages and restore flow. This reduces inflammation
and relieves pain. Here to answer questions about the practical use of
acupuncture for treating low back pain is Lora Alves. You know acupuncture has
been used as a Chinese therapy for 2,500 years to achieve wellness and to treat
pain and there are high-quality scientific studies that have shown the
value of acupuncture for conditions like migraine headache, fibromyalgia, low back
pain, and with respect to low back pain have you found the acupuncture useful
for treating acute low back pain? Low back pain is one of the main reasons a lot of patients come to see me and we’ve had wonderful results with people coming
in with chronic or acute symptoms, pain radiating up and down their back and
after it depends on the patient but after a few treatments many find relief. Is there a difference between patients who have acute low back pain and chronic low back pain with respect to the treatment that you
perform? Absolutely, I think in general the acute pain and is sometimes easier to treat or patients can find relief a bit faster whereas for chronic since it took a long time to create this pain the pain alleviation can take a lot longer to dissipate. In my opinion I really think that anyone can benefit from acupuncture whether they want to increase their quality of sleep, they
want to have a better body balance, and then there are people that might have
chronic symptoms, autoimmune disorders and I think really everyone can benefit.
Have you found certain types of pain more effectively treated with
acupuncture than others though? I think in general if I’m thinking about the
protocols that we use to treat pain and the kind of focus that we use to treat
the patient it really depends on the patient’s willingness to also
participate in their healing so if they’re willing to change diet or if
they’re willing to perhaps take Chinese herbs as well, we find that the results
can be a lot better. Talk to us now about the mechanisms of how acupuncture reduces pain. One of the ways is that it creates a local anti-inflammatory effect,
it can release endorphins the body’s natural feel-good hormones, it can also
release dynorphins the natural bodies of painkillers and a lot of these can
help to uplift mood it can help them it just feel better so that they can kind
of take more of an active role in their own care. Talk to us now about the actual
technique of acupuncture where do you place the needles and how do you know
where to place them? For us and for many people that might be squeamish when it
comes to needles your acupuncturist can use distraction techniques so that any
kind of discomfort can be avoided. We use special acupoints throughout the body
and these are located on channels and pathsways that run all up and down the body in a three-dimensional space deeper more
superficial and these unique points in conjunction with the acupuncture needle
placed precisely on this point can activate the body’s ability to heal it’s
almost like the acupuncture needle acts as an antenna calling the body’s
resources to help out a particular area that needs help. Now are these acupoints
called the meridians? The points are actually located on the meridians and
the meridians are what are running throughout the body up and down
according to a particular organ system. Ok and what are the meridians actually? The meridians might be considered pathways they’re considered channels
throughout the body and they’re channels where chi or life energy might flow,
they’re channels where the Yin fluids or body fluids, blood flows as well and when
these channels may be obstructed that’s what in our medicine can cause pain. Can patients who have shooting leg pain that is radicular pain, benefit as much from
acupuncture as say patients who have just low back pain, axial lumbar pain? I believe they can because the channel does run down the leg there are several
actually that run down the leg so if we activate one of the points and kind of
hit the right sweet spot it can actually help the nerve endings and the
inflammation that is causing the pain the right kind of fixing everything on
one shot. I’m also intrigued by auricular acupuncture and that is stimulating the
auricular branch of the vagus nerve how does that work and when do you use that
technique? In acupuncture the ear is considered a microcosm for the body so a
wide array can really be treated just by treating the ear it’s pretty
extraordinary so I can treat anything from low back pain to digestive issues
to stress and emotional disorders even allergies in the ear. Well so Lora when would you choose to use the ear though as opposed to other points on the body? If a patient were pressed for time or just did not want to get the systemic or
the body acupuncture because maybe it’s a winter day and their clothes and
they don’t have the time to disrobe or uncomfortable if they’re uncomfortable
with disrobing then we just stick to the ear acupuncture. Lora how would you persuade a primary care physician to recommend acupuncture over opioids? So pharmacological management is definitely one way to manage pain but for someone
who perhaps has a family history of addiction or might be prone to
dependence on opioids or really any kind of substance acupuncture is really a
wonderful way to get them treated and healed have some alleviation of pain
without this risk there’s no risk of dependence through acupuncture because
licensed professionals have to give the treatment but also it releases the own
body’s endorphins as opposed to kind of an external medication. By the way isn’t acupuncture also used to help treat opioid dependence or addiction? There’s a whole protocol actually that we use in the ear referred to as The NADA
protocol that I’ve used for people that wanted to help quit smoking or
dependence on other substances. And what have you found? They they’ve found it quite effective I’ve actually used it myself to quit smoking and for me it
changed the flavor of the cigarette so I just didn’t find it as enjoyable and
thereafter shortly thereafter I quit for many of my patients they found similar
experiences or they just didn’t have the craving as intensely as they did before
so slowly it’s it’s not an immediate process but slowly they did find less
craving less kind of pull toward that substance. The benefits of acupuncture
are cumulative. Patients should give acupuncture about 10 sessions in order
to evaluate effectiveness, and may often need concurrent use of medications or
nerve blocks as part of a comprehensive treatment program. Acupuncture is one of
many options we have available, and Thermal Therapy is another. Most people experience back pain at one point in their lives. In 2010, the number of
diagnosed cases reached about 83 million. Although the American College of
Physicians guidelines reccommend non-invasive, nonpharmacologic methods, it
seems that patients are still using opioid therapy. For instance, a large
randomized study of over 26,000 patients with low back pain showed that 61%
received a course of opioids, and 19% were long-term users. As Health Care
Professionals, our primary goal is to provide effective and efficient care to
our patients, while keeping in mind the long-term impact of our therapies. A
simple and effective first-line alternative to pharmacologic treatment
is Thermal Therapy. This is an inexpensive method, and easily applied by
practitioners and patients alike. Amber Bloom is here today to explain the
benefits of using Thermal Therapy as a first-line option. Thermal therapy can be used to reduce pain and a lot of patients that I have used different
types of Thermal Therapy. Can you describe for us what that is? Well by a Thermal Therapy they usually mean heat or cold.
So that could consist of an ice pack or a hot pack and hot packs could be what
we use in the PT clinic in a Hydrocollator moist heat is usually typically
more comfortable for patients especially those in acute pain or you could just
even use something as simple as a regular hot pack that you have at home
that you plug in one of those old-fashioned ones.
What about heating pads are those effective too? Yeah, they’re effective you
know heat increases blood flow and helps kind of bring in the good cells and get
rid of the bad cells so we do encourage that. When you recommend heat therapy for
patients at home. What do you recommend them for how long per day? You know it
depends on what they have access to so if they have a heating pad I say leave
it on 20 minutes make sure that you’re still awake so you don’t burn yourself
there are stick-on hot packs that lasts up to 8 hours and you’re not supposed to
sleep with them however if you have if you don’t have any sensory issues no
diabetes anything like that and you try it out while you’re awake you probably
could be okay sleeping with them if you wake up with morning stiffness that
tends to help. How about heat wrap therapy what does
that consist of? Heat wrap therapy we’re talking about the stick-on heating pads
that you can leave on for 8 to 12 hours I think they they’re very effective I
actually have a patient right now who is on a bike ride who is using one as we
speak I think they’re pretty they’re pretty
effective in keeping the joints a little bit looser the muscles getting more
blood flow and just overall it it feels good. Fundamental knowledge about nonpharmacologic methods of treating low back pain, like heat therapy should be a
focus for all Health Care Providers. This will help direct attention away from
opioids as a first-line therapy. Next we’ll explore the option of Massage
Therapy in the first-line setting. Despite the recommended guidelines,
medical use of opioids has risen 1,448% since 1996. During the same period, opioid misuse increased
by 4,680%. There are comparatively low
risks associated with the recommended non-invasive treatments, yet, among
general practitioners, the readiness to implement these recommendations is very
low. We can do better. Through awareness and education, we can offer relief for
low back pain, without risking abuse or addiction. We can also learn to detect
risk factors that may lead to opioid overdose. In some cases, pharmacological
treatment may be necessary, but most acute and non acute back pain resolves
on its own. Instead of pharmacological therapies, practitioners should consider
massage therapy for symptom reduction. I’m joined by Shea Davies.
Do you find that massage therapy is useful for acute low back pain as well
as chronic low back pain? It’s definitely in the acute form you know it would be
less working on the muscles directly and more just kind of trying to ease the
tension around the muscles, but it you know it is useful for both especially
chronic it’s a little bit more more helpful in that way just to keep them
keep the muscles trained to where they they need to be. What’s the mechanism of
action I mean how does massage therapy work to reduce pain? Well it works by
flushing out lactic acid in the muscles so you’re just you know similarly to a
workout when you’re sore afterwards you just want to get the blood flow into the
muscles get you know intention is often oftentimes the muscles are not
oxygenated by blood they’ve just gotten a little stuck on top of each other so
it works to take adhesions out and get all sorts of blood flow and oxygen back
into them. I’ve also read that it shifts the body from a sympathetic state to a
parasympathetic state. Yes that is probably one of the most important
factors of the massage is you know just taking us from the fight-or-flight
mentality to the rest and digest mode and that’s why I was saying in terms of
chronic pain and you know in acute pain you’re more working on just
easing the rest of the body so it doesn’t become like a domino effect of
tension and pain. Should it be considered as a first-line therapy for low back
pain? Absolutely massage therapy should be a first-line therapy for lower
back pain there’s a lot of healing that can be done just by getting blood put
back into the muscles if it’s an acute situation because it’s an inflammatory
situation you don’t necessarily want to get blood in there, but especially for
chronic lower back pain it’s it’s really helpful for relaxing the muscles around
that area and kind of retraining them to hold the body the way it’s it’s meant to
be. Is there a certain type of assessment that you perform on all patients? The
assessment that I do in all patients is I just ask them what they want to work
on and a history of injuries you know history of chronic
tension points and then what what type of pressure generally works for them. Can
you describe the different types of massage therapy for example therapeutic
massage versus rehabilitation massage versus relaxation massage. The different
types of therapy are all part of the same family with a little bit different
like Ingold results so therapeutic massage may also be described as Swedish
massage and that’s that’s meant to once again get blood flow back into the
muscles work on the parasympathetic nervous system work on resting digesting
and just relaxing the body and just letting its do it do its own healing
naturally. Rehabilitative massage is more used in companion with physical
therapy in order to get blood flow back into muscles that might have been
injured or to break up scar tissue within those muscles or and to just get
that joint or whatever it might be the mobility back and then
relaxation massage is also a form of Swedish massage and you know the
goal is to to really just like let the stress of the body go. Is there one
particular form of massage that you found more beneficial for patients with
low back pain? I have found that you know the basic Swedish, deep tissue in the
lower back, and also used with stretches for the hamstrings and the hips has been
really helpful. How do you decide which technique to use kneading versus
sweeps versus long strokes. I would have to say deciding which techniques to use
generally we use a combination of all those it also depends on where the where
the tension is and this case the lower back a lot of the tension and the lower
back has to do with the erectors and the lower back and then also the glute
muscles so it depends on the muscles the the erector is that those you use
a lot more friction technique whereas the glutes because they’re denser you you
use a lot like kneading and deeper strokes. What
about if they have low back pain alone versus low back pain and shooting leg
pain that is radicular pain do you feel like massage therapy can benefit those
types of patients? Absolutely massage is very good for you know their chronic
lower back pain and any residual pain that that being said I don’t think it’s
the only thing you should try if you’ve been having nerve pain I think that you
know there could be an underlying issue that you’re not aware of, but in terms of
like releasing sciatica pain which is often the cause of radicular pain
massage can be super helpful in that way and also it can be a little
intense. For generations, Eastern cultures have believed that massage therapy
offers powerful analgesic effects. Studies comparing massage to inactive
treatments have found that massage is better in reducing pain intensity and
disability for acute, and subacute, nonspecific low back pain. Massage
therapy can also be combined with other, non-invasive modalities, such as physical
therapy. Low back pain is a disabling condition that can cost patients an
average of $6,300 per year. It’s ranked sixth out
of 291, with regard to overall worldwide burden. It can cause depression, anxiety
and obesity, as well as other chronic illnesses. Patients with multiple
comorbidities are up to 53% more likely to receive pharmacologic care,
despite the recommended guidelines. This subset of the population is the most
heavily medicated as well. Physical therapy is a good solution to the
problem. It’s a commonly accepted form of managing pain, as well as maintaining or
increasing function. Physical therapy not only provides pain relief, but it also
encourages patients to engage themselves in their own care.
Amber Bloom is here with us to explain our physical therapy options. Physical
therapy is often a treatment for low back pain it modulates pain, it improves
function, and it allows patients to better engage in their own care if a
patient comes to you with low back pain how do you initially assess them. Well
you have to take their history how it started if it was traumatic versus insidious if it came on just gradually you have to take into account
their past medical history if there’s something systemic going on or what kind
of lifestyle they have if they’re sedentary and they said at a desk you
know 16 hours a day or if they are moving around if they have a job where
they have to lift a lot you have to take all of those into account.
Have you noticed whether physical therapy is more effective for patients
who have low back pain alone versus radicular pain?
I think physical therapy is beneficial for both because there are different
exercises different modalities different techniques we can use to help to address
both. Talk to us about how you actually perform physical therapy what is it that
you’re doing for patients who have low back pain? Well what you start with like
I said the initial assessment you find out you try and figure out where it’s
coming from whether or not they’ve seen a doctor first or the doctor has sent to
us you decide by what you find out on your evaluation so let’s say for example
if it were a disc herniation I would typically start with just seeing
what their range of motion is what their bias is whether or not they would prefer
flexion versus extension you go from there give them exercises there I always
send someone home day one with exercises for core strengthening because
no matter what happens if they have back pain even if it’s not even if they’re
strong to start with usually there’s a little bit of core instability that
happens just as your body’s way of protecting itself. I’m glad you mentioned
core what is the core what does that consist of? It consists of all of your
muscles basically here and in your back so you know in a lot of studies are
showing more that the deep core muscles like your transverse abdominus are very
very important in core stability you need those muscles to help contract to
stabilize you when you’re gonna do a motion like a pushing or pulling and if
they’re not functioning well and they’re very weak you know that’s something
that’s gonna cause you to have more back pain. As a physical therapist if a
patient has low back pain what techniques are you using to strengthen
the core? I usually start right away with just transverse abdominus trying to
contract that and one of my cues is usually try to hold in your urine and
just starting with that so you’re getting the deep core stabilizers first
because everyone always thinks it’s yeah it’s my upper abdominals I need to get
those muscles stronger I call those vanity muscles they’re not as important
as the deep core stabilizers. You mentioned holding your urine tell us
what that means? I just usually start them out on a table and I have them put
their hands right inside of their hip bones coughs and then you can feel that
those muscles will kind of tighten up a little bit then I asked some try and
hold your urine in you pull in and those muscles are tight in there they’re
trying to help stabilize because they’re the ones that are right above all your
perineum muscles that we want to get to work so it’s basically they have tactile
cueing on themselves so they can feel it. How long are they actually holding
it in? I usually yeah I usually have them start five seconds and once they’ve got
a good grasp of it and I have them do it at home usually for like two minutes
a night that’s it try and hold it for five seconds and relax set a timer do
that and then as they progress I’ll give them marches so they’re lying down and
they’re marching like this you know and then we make it harder put both legs up
and tap and it’s just a progression of those muscles of those exercises to help
get those muscles a little bit stronger What other modalities do you use in
addition to exercises to reduce low back pain. Ice and heat is usually what we use
to start with kind of modulating the pain. You can use E-STIM (Electrical muscle stimulation)
I also know kinesio taping so I like to use that with acute back pain so those are pretty
much where I stick to in my practice anyway. When I refer patients for
physical therapy who have acute low back pain how many sessions do you recommend?
I would say start with twice a week for four weeks and then see where
you’re at it’s it’s all specifically patient based and how they’re doing I
like to have a good relationship with the doctors so if they’re not getting
better send them back to you and maybe talk about medically not necessarily
pain you know like not opioids or anything like that but NSAIDs or
something like that to try it and see if if the regular the conservative
treatment isn’t helping. Are the techniques different for patients who
have acute low back pain versus chronic low back pain? Yeah, absolutely
I for chronic low back pain I am so focused on core strengthening and back
strengthening with that a cue it’s you you have to bring down the inflammation
first and then you kind of progressed more towards the higher level exercises.
How about kinesio taping? Kinesio taping that is a very
interesting type of treatment, but basically the tape has elastic
properties and the more you stretch it the more shrinks up so that it kind of
acts as a brace it works on your proprioceptors so it helps guide your
movements and it also sticks to the skin and kind of helps pull on it a little
bit and stretch out the fashio so that more blood flow can get to the area.
How long do patients leave it on? You can actually leave it on a couple days it
depends on how their skin reacts to it it is meant to be is meant to get wet so
a lot of you’ll see a lot of athletes in the Olympics wear it it’s sweat proof
you leave it on in the shower I’ve had people even up for a week.
What kind of benefit have you seen with kinesio taping in patients who have low
back pain? A lot of people really liked it they said it feels like it’s
it’s helpful and the fact that it’s almost like it’s supporting their
muscles in the back. Talk to us now about therapeutic exercise for low back pain?
Well it’s basically like we just what we just discussed the core strengthening
you could do like I said the transverse abdominis strengthening getting all the
muscles to kind of work a little bit better efficiently you always want all
of your hip muscles your gluteus medius and your glute max all of those muscles
to work together to stabilize the core I also will just prescribe stretches if
it’s necessary and for a radicular pain too depending on how they tolerate it if
the neural tension isn’t too much I would prescribe nerve glides which are
basically just stretching the nerve a little bit as part of their home
exercise program. How would you persuade primary care doctors to choose physical
therapy over opioids as an initial treatment for low back pain? I mean you
have to have a relationship with them so they trust you if you know a primary
care physician it’s about the relationships I think and they want to
see results. What’s important for all of us to remember about physical therapy
for low back pain? You should try it see if it works
if you’re not getting the results you want you let your physical therapist
know and they should be able to adjust your program and it is absolutely
important to be moving when you have back pain as much as you don’t want to
because it hurt so much that’s gonna make it worse in the long run. Physical
therapy is a time-tested resource for pain relief and spine stabilization.
Patients can even benefit from a combination of physical therapy and
other methods of non-invasive treatment, such as chiropractic care. The advantages
of nonpharmacologic treatment of back pain are clear. Studies have shown
that its impact can be significant. We have an opportunity to improve the
public health of our country by directing our attention to non-pharmacologic therapies for low back pain, and avoiding the non-medical use of
prescription opioids. Once we’re informed of these guidelines,
and begin to implement them, we can offer methods of pain relief to patients with
low back pain without risking opioid addiction. Let’s now explore chiropractic
care as a non-pharmacologic option for low back pain. I’d like to introduce Dr.
Jeannette Anderson. Dr. Anderson what is chiropractic care about?
Chiropractic care is a primary portal of entry for helping conditions of the
spine we commonly see patients that are acute for low back and neck pain
chiropractic care helps neuromuscular conditions of the spine by treating them
with chiropractic manipulation which is manual adjustments or instrument
adjusting to take the pressure off the nerves in the spinal column to ease the
pain or symptoms. You mentioned adjustments. Yes. I think
those entails spinal manipulation is that right? Yes. Talk to us about
that, what is that about and what are you actually achieving when you perform
spinal manipulation? What happens with a adjusting is is that your nervous system
which is the direct extension of your brain goes through the 24 freely
moveable vertebrae of your spinal column you have in between each of those 24
freely moveable vertebra a disc that acts like a shock absorber and
actually adds space for pairs of nerves to communicate with the body so if there
is a problem with the pressure on the nerve that can be caused by either the
vertebra being on it a disc that has moved some of the soft tissue any of
that joint complex the nerve does not fire the right way so what happens is
that the patient will usually feel some kind of symptom which is usually pain.
In order to do that in order to do this spinal manipulation are using high
velocity low amplitude thrusts? Yes. What does that really mean? So a high velocity low
amplitude thrust is what a manual adjusting does by the use of our hands
and so what will happen is we’ll move that segment and you move it a little
bit past what a normal range of motion would be so you could put it back in
place you’re actually with that you might hear a sound it’s not bones
cracking that’s another misnomer of what a doctor of chiropractic does, but it’s
actually an exchange of gas it’s almost like that it’s called cavitation and
that gas is in between the joint spaces where the discs are it’s almost like
when you pop a helium balloon you hear the pop yeah it’s the same kind of thing
when you move the bone it’s just an exchange of gas and the the thrust that
you put down it’s very quick so that’s where the high velocity low amplitude is
low amplitude is is you’re not really moving it that far it’s just the power
of the thrust. Do you feel that chiropractic care can help patients who
have acute low back pain as well as patients who have chronic low back pain?
Acute low back pain patients are usually seeing multiple times per week for three
to four weeks and then a reevaluation is done and at which point there should be
a large reduction in symptoms and also some low acute low back pain will also
over time improve where somebody with chronic low back pain usually can have a
comorbidity prior surgeries other things going on history of accidents manual
labor etc and those are the kinds of patients that you want to
keep keep going in there lifestyle right so they can continue to work so
lifestyle and recommendations are usually important for these patients.
Dr. Anderson is there a certain type of low back pain that benefits the most from
chiropractic care? Yes, there is, it’s usually neuromuscular it’s something
related directly to the spinal column it would be inflammation on the nerve
itself from either a spasm muscle or a disc yet something that doesn’t involve
radiculopathy. Now here’s a question that I think a lot of people are gonna want
to know. What can you do as a chiropractor to prevent low back pain
from occurring? It’s really about lifestyle. It’s about learning how to
sleep correctly it’s learning how to use your computer with proper ergonomics at
your workstation it’s about eating correctly as far as diet it is about
exercise it is about reducing stress it is improved emotional health and
improved mental health it’s really about how you are as a whole person so it’s
not just back exercises which people always get and it’s not just about
simple tips it’s really about how you live your life. The American College of
Physicians strongly suggests the first line use of non pharmacologic,
non-invasive therapies to reduce pain, stress, increased mobility, and improved
quality of life. The more Health Care Providers become aware of non-opioid
strategies for easing low back pain, the closer will come to combating the opioid
epidemic. We hope you found these demonstrations both informational and

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