Conquer Back and Neck Pain - Walk It Off! (24 page)

Evidence-based medicine is the process through which the medical community determines the effectiveness and safety of a treatment, with that determination being based on four different levels of evidence.

Level I evidence is derived from the results of well-designed clinical trials. This usually means a prospective, randomized, placebo-controlled study. A systematic review, meta-analysis, of a large number of peer-reviewed publications on a treatment also qualifies as Level I evidence.

Level II evidence means that there is at least one well-designed study or that multiple low-quality clinical trials have been reviewed.

Level III data comes from case series, studies not using placebo controls, and studies that compare results to historical controls.

Level IV studies are comparisons of multiple case series from different institutions.

The evidence-based effectiveness of a medication does not guarantee its availability. For example, chymopapain (chymo), an enzyme from the papaya fruit, was widely used throughout the world to dissolve herniated discs. There were three prospective, randomized, double-blind studies (neither the patient nor the doctor knew whether chymo or a placebo was being injected) from three countries that showed chymo was better than placebo to treat disc herniations. There were also several meta-analyses that showed the safety and efficacy of this treatment.

This was strong Level I evidence to support the use of chymopapain! Some of my most satisfied patients were those who I treated with chymopapain for their disc herniations. Despite strong proof that chymo works, it is no longer available in North America. Why? Approximately 3,000 vials of chymopapain were sold per year in the United States, at $1,500/vial, for a total of $4.5 million revenue for the manufacturer. This revenue didn’t even cover the liability insurance, let alone the production cost. Consequently the manufacturer stopped selling chymopapain in the United States in the early 1990s. Therefore a proven, safe, and effective method of treating herniated discs without surgery is no longer available. The same problem of liability cost has prevented adequate supply of flu vaccines in the United States in the past.

The most commonly prescribed pills for back pain are anti-inflammatories, narcotics, and muscle relaxants. Over-the-counter anti-inflammatory pain medications work the best, are the safest and the least expensive of all the pills that are available for back pain. Ibuprophen (Advil) and naproxen (Aleve) are the two most popular over-the-counter anti-inflammatory medications. Like all anti-inflammatory medication, they can cause bruising, indigestion, heartburn, and gastrointestinal (GI) bleeding. They can also cause fluid retention with leg swelling. This can lead to elevation of blood pressure. People with kidney disease should not take these medications.

The anti-inflammatory effect of aspirin is the gold standard against which all others are measured. As good as aspirin is in relieving musculoskeletal pain, it has the major disadvantage of causing gastritis and GI bleeding. Most men who I see are taking a baby aspirin, 81 mg/daily, as a preventative measure against a heart attack. It is useful for this because it inhibits blood clotting. Most people who do not have a pre-disposition to stomach upset can tolerate this low dose. However, between two and six aspirin a day (up to 1,800 mg) is needed for relief of back pain. These high doses of aspirin can cause life-threatening gastrointestinal bleeding, which is obviously a big risk to take for relief from benign back pain!

In my father’s day, aspirin was the only anti-inflammatory medicine available. Although aspirin gave him relief from his back pain, he did complain that it caused him to have heartburn. To the best of my knowledge he never had any GI bleeding from it, but he did not take it very often, and when he did it was for a short period of time. Ibuprophen and naproxen are safer than aspirin with respect to GI bleeding, and they work as well as aspirin to relieve back pain. I do not recommend that you take aspirin for back pain. Nor do I recommend that you take any anti-inflammatory medication in large daily doses, or for more than a few days at a time.

The COX-2 inhibitors, Vioxx, Bextra, and Celebrex, are anti-inflammatory medications that were designed to give you pain relief without causing bleeding or indigestion. They do not irritate your stomach or cause bleeding as often as the anti-inflammatory medications mentioned above (the non–COX-2 inhibitors). When Vioxx was given on a daily basis for more than one year to a group of patients it was associated with close to a 4 percent incidence of heart attack or stroke compared to a 2 percent incidence of these events in an equivalent group of individuals taking a placebo. For this reason Vioxx, and subsequently Bextra, were taken off the market by their manufacturers. Celebrex is still available but is far less popular than it was before these findings were made public.

COX-2 anti-inflammatory medication like Celebrex requires a doctor’s prescription and is expensive compared to over-the-counter anti-inflammatory medications. However, its advantages are that you only require one pill day for effective relief of back pain and it can be used prior to spine surgery since it does not cause bleeding.

The anti-inflammatory drugs available to you today are safer than aspirin. However, I tell all of my patients not to take any anti-inflammatory medication on a daily basis. I tell them to take the medication one or two days in a row at the most. If they get relief, do not take them again unless the symptoms come back. No matter what, they should allow a one-or two-day interval between taking these pills to give their stomach a rest. If you develop heartburn or indigestion with any medication, stop it immediately. Also stop taking the medication if you develop black stools, which may mean stomach and intestinal bleeding.

The most potent of the anti-inflammatory pills that you can take are steroids. I discussed the benefits and risks of a short course of high-dose steroids (Medrol Dose-Pacs) in
Chapter 3
. I do not recommend steroids because there is not a good clinical study to prove that they are any better than your body’s ability to relieve the pain on its own, and they have so many potentially serious side effects. A good prospective, randomized study of oral steroids versus placebo for the treatment of acute low-back pain and sciatica would show whether steroids are worth the risk. President Kennedy was treated with steroids for chronic low-back pain when he was a young man, with serious consequences! He was given too much steroid medication over too long of a time period, which caused his adrenal glands (the glands that produce your own body’s steroids) to permanently stop functioning. This resulted in a condition that requires that you take steroids the rest of your life. If you do not take them, you develop symptoms that can be life threatening. Granted, today doctors are aware that too much steroid can cause this complication, and this is the reason why safe dosage schedules where developed (Dose-pacs), but I still see patients who have been treated with more than one series of steroids who are at danger of developing a dependency on steroids similar to that which plagued President Kennedy for much of his life.

Acetaminophen (Tylenol) is the most popular over-the-counter non-narcotic pain medication in North America. It does not irritate your stomach and does not cause bleeding. However, too much Tylenol can cause liver damage. Also, if you are known to have liver disease, history of hepatitis, or drink heavily you should not take acetaminophen. I do not recommend to my patients that they take more than six Tylenol daily (total daily dose of 1,800 mg). And I do not recommend that they take it on a daily basis.

Narcotic pain medication must be prescribed by a physician. The most prescribed narcotic painkillers in North America are, in increasing order of potency: Codeine, Tylenol with Codeine, Darvocet, Percocet, Morphine, Vicoden, Dilaudid, Oxycontin, Oxycodone, and Methadone. They are highly effective for relief of acute pain, such as post-operative pain. The big problem with narcotics is that they deplete the body’s natural painkillers (endorphins) within your body. This begins to happen within three or four days of taking them. When your endorphins are depleted you become depressed, and this in turn causes you to suffer more from your pain. Also, narcotics make you drowsy, impair your driving skills, and are constipating. Narcotics make some people become hyper. Since most back-pain conditions are relatively benign (not cancer), tend to last more than three days and recur frequently, and narcotics have so many side effects when taken for more than a few days, I do not recommend them to my patients for chronic back pain. On the contrary, I try to take patients suffering from chronic back pain off of narcotics when I think that they are contributing to the suffering. The objective of this approach is to relieve their suffering from chronic pain and improve their quality of life.

Most oral narcotics are not habituating, so people do not become dependent on them. That is, you can rapidly wean yourself off of them without having withdrawal symptoms. However, strong narcotics such as Oxycontin, Methadone, Fentanyl, and Dilaudid are the exception. I have observed that patients who are taking these potent narcotics require escalating doses of them to obtain relief of pain, become depressed and dependent on them, and they have withdrawal symptoms when they stop taking these drugs. For these reasons I do not ever prescribe potent narcotics to my patients, except in the immediate post-operative period. I have also found that the patients I see who are taking these drugs for chronic back pain are still complaining of their pain, therefore the pain medication is not working anyway! In fact, the pain medication has become one of the primary causes of the pain in some patients, and lasting pain relief depends on stopping them. It is difficult to explain this to patients who have chronic pain that is enhanced by the painkillers that they depend on for relief. Some patients will not believe this explanation and will continue to suffer from chronic pain. I have never seen a patient who requires a large amount of narcotics for chronic back pain obtain satisfactory relief and a good quality of life. However, I have seen numerous patients with chronic back pain who have been cured by being weaned off of narcotics!

Muscle relaxants fall into the same category as potent narcotics when it comes to causing depression and enhancing chronic pain. Muscle relaxants lead to depression, are habituating, and it is difficult to stop taking them. Patients frequently tell me that they were previously prescribed a muscle relaxant that they stopped taking because it made them drowsy and did not relieve the pain anyway. If you have been taking Valium or other potent muscle relaxants for an extended period of time, you must be weaned off of them slowly, over a period of time. A too-rapid withdrawal of these medications can lead to seizures, so you should ask your doctor to give you a safe schedule for stopping them. I do not recommend muscle relaxants to my patients for relief of chronic back pain. However, I will prescribe one dose of Valium to my claustrophobic patients to help them get through an MRI scan because it makes them less aware of what is happening and thereby relieves their claustrophobia.

Two frequently prescribed medications for neurogenic back pain are Neurontin (the generic form is Gabapentin) and Lyrica. They are commonly prescribed for chronic nerve pain as an off-label use (use of a drug for a purpose other than what it was approved for). Gabapentin is a U.S. FDA–approved anti-seizure medication. Neurologists (specialists in diseases of the nervous system, brain, spinal cord, and nerves, see page 40) have also found it to be useful in treating abnormal sensations experienced from peripheral neuropathy (a disease of the nerves that causes annoying sensations in the lower legs, usually seen in diabetics). They then began using it for patients with chronic nerve pain from spinal stenosis. Like some narcotics and muscle relaxants, it causes drowsiness and it must be withdrawn slowly. Many patients have told me that the side effects of this drug are not worth the relief it gives them. I prescribe these for some patients with neurogenic pain (see
Chapter 6
), but most of the time I wean patients off of these drugs because they are not helping to alleviate the symptoms for which they were being prescribed.

Pain-management specialists frequently prescribe slow-release skin patches containing narcotics (Fentanyl) and local anesthetics (Lidoderm) for chronic back pain. I find that it is very difficult for patients to wean themselves off of Fentanyl patches, a potent narcotic that is quite addictive. Lidoderm patches are not addicting, and I find they are useful for some patients with nerve pain. Lidoderm patches can only be used for 12 hours at a time, and I prescribe them for patients who are having difficulty sleeping because of nerve pain in the legs or arms. I think they should only be used for acute pain and for a short period of time.

We will look at ridiculous things like “astronaut chambers” and hanging traction to physical methods that have been proven through evidence-based medicine, such as aerobic exercise and some forms of traction. I will then recommend the physical treatments that I have seen help my patients. Physical methods of treatment include immobilization in corsets or braces, chiropractic, massage, electrical stimulation, physical therapy, heat and ice, acupuncture, TENS (transcutaneous electrical nerve stimulation) traction, manipulation, and trigger-point acu-pressure.

I have studied the chiropractic method and used this method to treat selected patients throughout the years. Chiropractic has a place in relieving certain painful conditions of the spine, especially acute back pain in young adults. However, there are some older patients for whom the method should not be used, which I will explain later. Like other treatments for back pain, such as medications and surgery, it tends to be overused. Here is how I use chiropractic and when I think it should not be used.