"Like an expensive but temperamental sports car," Claudia Kalb writes in this week's cover story on back pain, "the human spine is beautifully designed and maddeningly unreliable." As millions can attest, the spine isn't shy about asserting its unreliable nature, frequently and painfully. But while back pain has always been crippling, doctors' explanations of its causes, and of the best way to treat it, have changed in recent years. In her piece, Kalb details new research indicating back sufferers' aching bones could have as much to do with the strain inside their head—taxing psychological woes—as it does with the strain on their frame. Armed with this data, some physicians are steering their patients away from invasive and expensive surgery towards more holistic approaches like massage therapy and acupuncture. How can back pain sufferers figure out what's making them ache? At what point does a sore back become a debilitating disability? What's the best way to finally stop the pain? Claudia Kalb answered these and other questions in a live talk on Thursday, April 22 at noon, ET. Read the transcript below.
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Claudia Kalb is a NEWSWEEK general editor, focusing on health and medical issues. She has worked on a variety of cover stories including features on alternatives to hormone therapy, prescription drug addiction, treatment for alcoholism and Alzheimer's disease. Since she first joined NEWSWEEK in 1994, Kalb's work has taken her to postings in Boston, Chicago and New York. In addition to her time at the magazine, she has also worked for the Associated Press, Boston Magazine and the Jakarta Post in Indonesia, where she wrote two books for Indonesian schoolchildren studying English. Recognition for her work includes a fellowship at the Casey Journalism Center for Children and Families (June 1998), a Knight mini-fellowship at the Knight Science Journalism Fellowships at MIT (December 1999) and, most recently, a John S. Knight Fellowship at Stanford University for the academic year 2001-2002. An alumna of Amherst College, Kalb received a master's degree in international relations from Columbia University.
Claudia Kalb: Hello, Thanks for joining in. I’m Claudia Kalb and I wrote this week’s cover story on back pain. I’m looking forward to answering your questions on this intriguing and frustrating condition. I’d also like to put a plug in for a special question and answer section we are offering on women’s health. If you have medical questions relating specifically to women's health (including questions on back pain), you can submit them to Celeste Robb-Nicholson, M.D., editor in chief of The Harvard Women's Health Watch, by clicking on this link after the chat is over: http://www.msnbc.msn.com/id/4703586/.
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Shoreview, MN: It seems I only have back pain when I sit too much and don't exercise. It seems the old myth of protecting yourself from "backbreaking" work or even walking is not very true.
Claudia Kalb: You’re right. Exercise is critical to a healthy back. That’s because the discs in your back, which are fat and full of water when they’re healthy, take fluid in through movement. If you spend endless hours sitting in front of a computer or TV, you’re putting pressure on your discs and you’re denying them the critical nutrition they need. If you’re sitting or driving for long periods of time, be sure to get up and walk around every hour or so. Exercise, especially workouts that strengthen your back muscles and abdominal muscles, will help ward off muscle, ligament and tendon strains, which can lead to those horrible spasms.
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Elsmere, KY: I was recently offered a new procedure, IDET, over a spinal fusion, however my insurance doesn't cover this. What other type of procedure is there that's not as invasive as spinal fusion?
Claudia Kalb: IDET is still considered experimental. Some data have shown that the procedure (which works by heating the painful disc with an electrothermal catheter) can help, but other studies have found mixed results. There are many new techniques now being tried, including “minimally invasive" therapies where doctors use smaller incisions and tools. In a discectomy, for example, some of the damaged disc material is removed—a less invasive alternative to fusion, which requires removal of the disc and a bone graft. Many of these minimally invasive procedures are still being assessed for long-term effectiveness.
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Oakland, NJ: Why is chiropractic care not used more often when it has been proven to be a safe, conservative way of treating back pain.
Claudia Kalb: It’s actually used quite often. As we say in the story, the number of chiropractors has jumped 50 percent in the last 10 years or so. That’s because there’s huge demand from patients. Chiropractic is now being rigorously tested and is even being included in more conventional medical settings. The bottom line is that chiropractic can clearly help some patients, many of whom swear by its effectiveness. One recent and large overview of the medical literature on chiropractic found that it didn't work better than other remedies, like physical therapy or exercise. A new study of more than 600 patients should provide some more solid answers soon on just how effective it is for back pain.
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Germantown, MD: In your opinion, what is the most effective type of treatment or therapy to relieve back pain if you have symptoms of a herniated disc?
Claudia Kalb: I wish I had an answer! The reality is that there is no one clear prescription. Some people with herniated discs don’t even realize they have an anatomical problem ... so should the pain actually be treated at all? That’s a question doctors face every day. A discectomy (described above) can help some patients with a herniated disc—in one study, about 70 percent of patients who had a herniated disc and sciatica (the terrible pain that results from pressure on the sciatic nerve) said the procedure improved their condition. It’s unclear, however, how long the benefit lasts. The key is to start with noninvasive therapies, like physical therapy or massage, before going the surgical route.
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New York, NY: Did Dr. Sarno give an explanation as to why he has never published academic research on his approach? I've read his book and met him in person, and I think he either said something about the medical community not accepting his findings, or that he simply has not had the time. However, if his approach works as well as he and his patients say, the lack of objective data seems to be the main reason why he hasn't achieved widespread acceptance among doctors. It's pretty surprising that he hasn't published anything academic, considering that he makes a big point about how revolutionary his findings are and how the medical community has gotten it wrong this whole time. A cynic might suggest that his primary motivation is in avoiding competition.
Claudia Kalb: Yes, Sarno is quick to admit that the mainstream medical community doesn’t think much of his approach. We asked him about data and he said he simply doesn’t have time to focus on publishing his findings in medical journals. The reality is it would take a lot of money and a lot of time to come up with a decent study—i.e., a group of patients receiving his treatment versus a control group receiving some other kind of care or no treatment at all. And it wouldn’t be easy to do on a practical level either since you wouldn’t be able to “blind” the patients (keep their treatment secret), which is the gold standard in medical research.
Critics say his belief in the psychology of back pain is way too narrow-minded. He says he’s addressing the true cause of pain and that everybody else is just taking care of symptoms. Clearly, the lack of medical data on his methods is a problem for mainstream medicine. He’s now writing another book which explains his theory and includes input from a handful of doctors who’ve embraced his ideas.
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Rockville, MD: Most of the treatments mentioned in the article are passive treatments. Very little is mentioned about people with back pain trying to determine what activities may actually be contributing to their back pain. Doctors of Physical Therapy (DPT) are the experts of movement and we can provide patients with important information that can be used by the patient to manage their symptoms. Physical therapy goes much more beyond "massages." Why is it that although many back-pain patients are treated by physical therapists, not once does the article mention physical-therapy interventions that not only relieve pain, but correct the root of the movement impairment causing the pain?
Claudia Kalb: Good point. I wish I’d had more space to describe physical therapy more thoroughly in the piece. The focus was on surgery and complementary and alternative methods since these are the paths many patients choose when other treatments fail. Readers who are interested in learning more might want to go to the American Physical Therapy Assocation’s Web site (http://www.apta.org/Consumer). There’s also some good overview information on back pain at the National Institutes of Health (http://www.nlm.nih.gov/medlineplus/backpain.html).
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Plymouth, MI: How effective is acupuncture for back pain? Will that relieve joint or muscle pain, and is it worth the expense?
Claudia Kalb: The effectiveness of acupuncture is still unclear. Some patients report that it helps, or at least that it makes them feel better. I can’t make a recommendation one way or the other. Given the complexity of back pain and the frustration in treating it, however, many doctors we talked to said they’d have no problem with patients trying acupuncture since it’s not dangerous and it might provide relief.
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Truckee, CA: GREAT ARTICLE!!! ... You mention that the torment will usually go away on its own. Might that be better described as the body is good at adapting ... that the pain can serve as a signal of disruption and 'insult' within this wonderful organization of tissue. The body, once it has adapted and compensated, will get up and move on ... The problem has more often than not has been moved down the priority list ... its now time to get on with life ...
Claudia Kalb: The science of pain is incredibly interesting, mysterious and frustrating at the same time. As I researched back pain, I was amazed to learn about the studies showing a disconnect between structural defects (an abnormal disc) and the way a patient actually feels (a lot of pain or no pain at all). The body clearly adapts to insults and injuries every day and seems to prioritize pain. That's why a doctor might pinch the skin before making an injection—to distract the patient. Or why parents instinctively offer kisses or ice cream to a child who has skinned her knee—distract the mind and the pain will go away. I talked to one back-pain sufferer who said his back pain completely disappeared when his wife slipped and fell in the house; he was so worried about her that he forgot about his back.
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Sanford, NC: Is there any focus on the cause of scoliosis or its cure? Is it due to weak muscles or week dics? I have had to have spinal fusion surgery that has left me in more pain then I experenced prior to my surgery. It seems to me that there should be some less debilitating was to correct the problem.
Claudia Kalb: The focus of the piece was on lower-back pain rather than structural problesm like scoliosis. The National Scoliosis Foundation has a lot of information on its Web site which may help you learn more: www.scoliosis.org
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Wayne, NJ: In the recent NEWSWEEK article its states a correlation between depression and pain. Can a pain reliever help the efficacy of an antidepressant? Is there need to reduce inflammation first before you can help your mental wellbeing?
Claudia Kalb: I'm not aware of any studies that show that pain relievers can help improve the effectiveness of antidepressants. But there's clearly a link between depression and pain. One of the researchers we interviewed said that one third to half of people with chronic back pain go on to develop depression at some point in their battle against the agony. Research has shown that treating back pain with antidepressants can help some patients, which is why doctors are continuing to study this interesting area. Stay tuned for more data.
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Lake Forest, CA: When should a patient undergo some of the more invasive diagnostic tests, such as myelogram and/or discogram? Also, when are these tests likely to provoke more pain if the diagnosis isn't readily apparent?
Claudia Kalb: Many doctors believe a discography is critical to pinpointing the source of pain, especially after patients have failed at finding relief through noninvasive therapies. But it’s painful and there’s a slight risk of nerve root damage. There can also be false positives on these tests—one study found that patients who did not complain of any pain at all actually felt pain when they had a discography. As for causing more pain—it’s hard to know since patients who have a discography are already suffering. This is one of the problems in the back-pain field: there’s no easy diagnostic (like a blood test!) to determine precisely where the pain is coming from.
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Claudia Kalb: Thanks so much for all of your interesting and important questions--I wish I could have answered more of them. In addition to the Web sites offered above, here are a few more that might be helpful as you research the topic: the American Academy of Orthopedic Surgeons (www.aaos.org); the American Association of Neurological Surgeons (www.aans.org); the North American Spine Society (www.spine.org); the American Massage Therapy Association (www.amtamassage.org), the American Chiropractic Association (www.amtamassage.org).
Just be sure to do your homework—read up on the options, talk to your doctor and be sure to get a second opinion. Thanks again for your questions.
