Dr. Keley John Booth, MD shares insights from an Interventional Pain Specialists perspective in order to help you with your low back pain options.
Low back pain is the most common musculoskeletal condition in adults. As many as 84% of the population will experience low back pain at some point in their lives. In the United States alone, total costs related to back pain is reported to be $100 billion annually. The majority of this expense is from lost wages and reductions in productivity of those suffering this disabling condition. Given the widespread occurrence of low back pain conditions, including sciatica, sciatic nerve pain, lumbar degenerative disc disease, radiculopathy, sacroiliac joint pain, and lumbar osteoarthritis, it is likely that you or an immediate family member are personally suffering back pain. The real question is – what should you do if you have back pain?
The answer to that question depends on many factors, not the least of which is – whom you are asking? As an Interventional Pain Specialist, I have had the opportunity to hear the wide variety of answers provided by the many types of healthcare providers.
“What you should do if you have back pain? Well, it depends on whom you are asking?”
Consider this, www.health.com wrote in a recent article titled 4 Specialists That Can Help Your Back and How to Pick One, that you need to “shop” for the “back-pain specialist who is right for you”. This is troubling advice considering that one “shops” for clothes, jewelry, or vehicles. Making a poor choice when “shopping” usually doesn’t lead to a delay in a life changing diagnosis such as low back pain. Depending on the choice you make, you could develop a worsening medical condition that ultimately could limit your ability to work, perform home activities, or even move normally.
Common Providers of Lumbar Pain Treatment Advice
The long list of those healthcare providers commonly involved in advising patients about back problems includes:
- Primary Care Doctors (Family Medicine & Internal Medicine)
- Nurse Practitioners (Primary Care Providers)
- Interventional Pain Specialists (usually Anesthesiologists or Physiatrists)
- Orthopedic Surgeons
- Interventional Radiologists
- Pain Doctors
- Pain Medicine Doctors
- Physical Therapists
- Massage Therapists
However, most back pain patients are not able judge the experience level of the healthcare provider they are visiting with about their back. Therefore, “shopping” for a back specialist is not a good option for most. Hence, I have provided this article for those struggling with what to do about back pain and where to seek specialist low back treatment advice and options. Below, I provide a brief overview and perspective. This is not meant to be a comprehensive review of each provider and specialty type and you should always consult a licensed medical professional when seeking care for any serious medical condition.
Primary Care and Pain of the Back
Many may recommend you ask your primary care doctor’s office what to do. Unfortunately, it is not always possible to get clear and definitive answers you are seeking for your pain condition. The first hurdle is trying to secure an appointment, which can delay you for weeks and even months in some cases. There are a number of reasons that primary care doctors, such as in Family Medicine, may not always meet the expectations of patients in regards to addressing their aching backs.
According to an article in publication Family Medicine, “primary care physicians spend more than half of their workday interacting with the EHR”. I haven’t seen a study on it yet, but my guess is that the answer to your back pain won’t be found by spending more time with the computer. The reality is that primary care providers are under extreme pressure to be productive (see more patients in less time) and this doesn’t often allow the appropriate focus on your back, lumbar spine, sciatica, or leg pain. Proper evaluation and diagnosis of back related pain can often be among the more complex office visits provided by your family doctor – and many simply don’t have the time necessary to complete this important pain care.
An article published in 2017 on patient perspectives of communication with their primary care doctors about low back pain in Kaiser Permanente’s The Permanente Journal reports:
“Research has found that patients with chronic low back pain expect physicians to offer diagnostic tests, a diagnosis, information on prognosis, prescription medicines, and referrals”
They also reported that:
“Patients believed that their visit was incomplete when physicians did not perform a physical examination of the affected areas, including touching/palpating painful areas. They also complained about physicians who did not ask them enough questions about their history…”
“Patients wanted physicians to give clear and specific diagnoses with information about what can be done to minimize future damage.”
A theme emerges as you go through the patient expectations above, primary care doctors and providers can be overwhelmed when attempting to properly evaluate, diagnose, and provide treatment for your low back. Given the limited amount of time virtually all primary care providers have for spending with patients, it is simply not the best environment to meet the clearly stated needs and wants of those patients suffering low back pain.
Ultimately, this is a critically important reason why I highly recommend an evaluation by a specialty-trained doctor that specializes in low back management. A pain sub-specialist is able to evaluate, diagnose, and provide treatment while coordinating comprehensive care for your back condition as required for the best possible outcome. We routinely interact with our patients’ primary care providers to keep them updated and aware of your treatment, progress, and other recommendations. In addition, patients don’t realize that a referral from your primary care doctor is virtually never required. Start your pain assessment with our three minute online Back Pain Score.
Interventional Pain Management Specialists – Anesthesiologists – Physiatrists
This designation is often used for those medical doctors that focus on the multi-modal treatment of spine related pain disorders and particularly low back pain, sciatica, sciatic nerve pain, spinal stenosis, degenerative disc disease, facet arthropathy, spondylosis, herniated discs, bulging discs, neuroforaminal stenosis, among others. Many Interventional Pain Specialists, such as myself, also provide therapy for major joint related pain such as for knee osteoarthritis as well as hip, shoulder, and sacroiliac joint disease. In my case, I also provide complete medical management and medication optimization, which includes conservative chronic opioid management. Another specialty feature is the oversight of the spine and joint related care of patients including physical therapy, medications, and pre or post-surgical care follow-up as necessary. Many patients find our ability to provide advanced levels of interventional care a major advantage of working with specialists in this area, however there are a relatively limited supply of medical professionals with this extensive training and background.
Anesthesiology – Pain Specialists
The vast majority of Interventional Pain Specialists are Anesthesiologists. From the very beginning of our sub-specialty education, Anesthesiologists are trained to provide relief of pain utilizing the most advanced techniques to provide spinal and regional procedures that yield pain relief. The requirements to become a Board-Certified Anesthesiologist are rigorous and require training for a minimum of twelve years after graduation from high school. The other subspecialties that may obtain some of the specialized training and experience in this field include Physical Medicine doctors (Physiatrists), Interventional Radiologists, and very rarely Neurologists.
“Pain” Doctors and Pain Medicine
It may come as a surprise to patients reading this, but there is no standard definition for a “Pain” doctor. The backgrounds, training, qualifications, and specialties of professionals referring to their field of focus as Pain Medicine or “Pain” doctors often vary wildly between practitioners. General (non-subspecialty trained) doctors, Family Medicine doctors, Internal Medicine doctors, Psychiatrists, Neurologists, and even some retired surgeons consider themselves practicing in this area of focus.
Usually, a Pain doctor or Pain Medicine doctor designation indicates a focus on the medical and medication management of patients’ chronic pain generally, not specifically for low back. This designation most often is used by practitioners providing chronic opioid medication management – but not always. Typically, you will need to be seen by another specialist for a more comprehensive evaluation and/or treatment options for your pain condition. These providers do not offer interventional treatments such as nerve blocks, nerve stimulators, epidurals, and other advanced treatment modalities.
Neurosurgeons & Orthopedic Spine Surgeons
It is my opinion that all too often, primary care physicians refer patients to surgeons with an unconfirmed diagnosis and limited use of other less invasive treatment options. As it turns out, this isn’t just my opinion from years of clinical experience in treating spine patients in Oklahoma and Texas.
A recent medical journal article published in The Spine Journal in 2018 concluded:
“Evidence-based medical interventional treatments for patients with low back pain are not being taken advantage of before spine surgery consultation. If more patients were to undertake endorsed conservative modalities, it may result in fewer unnecessary referrals from primary care physicians, and patients might not deteriorate as much while lingering on long wait lists.”
This is one of the reasons I advocate for any patient suffering back pain unresponsive to conservative therapy to undergo evaluation by an Interventional Pain Specialist. Spine pain specialists are uniquely suited to provide rapid and specific diagnosis of the source of the pain (aka “pain generator”). Subsequently, following a proper evaluation and diagnosis, non-surgical treatment options have the potential to provide significant relief of low back pain and ultimately the recovery of function for most patients.
Often, there can be the development of behavioral manifestations of pain commonly including anxiety, depression, or both. A Psychiatrist may be a valuable addition to a multi-disciplinary team treating the most complex chronic low back pain cases. Their knowledge and experience with anti-depressants, anti-anxiety treatments, and counseling can be a valuable addition for selected patients. Typically, Psychiatrists are not willing and may not be experienced in managing the comprehensive aspects of evaluation, diagnosis, and interventional treatment of low back pain. As a spine specialist, I would recommend against seeking back pain related care from a Psychiatrist as the only provider of care.
Evaluation, treatment, and management of physical therapy plays an integral role in the ongoing care of patients suffering from both acute or chronic low back pain. When utilized in conjunction with comprehensive interventional spine care, I have found that patients respond better to treatment. There is the added benefit of reducing the likelihood of further injury and possibly slowing the development of pain associated with the aging degenerative spine. Reduction of muscle spasms, improving range of motion, strength, and balance are all potential benefits. In addition, physical therapy is often a critical part of recovering from musculoskeletal surgery of any kind.
Chiropractic Evaluation and Treatment
Literally millions of people have sought care from Chiropractors and many have identified improvement in their symptoms as a result. The primary challenge has been the significant variability of the methods involved in evaluation, diagnosis, and treatments utilized by chiropractic practitioners. The types of therapy and treatment provided between different providers can vary extensively for the same diagnosis. In my experience, Chiropractors that are open to working with other professionals in a collaborative manner offer the best opportunity for patients to improve their condition.
The reality is that any specialist should be capable of recognizing the limitations of their chosen profession and you should be wary of those that are not prepared to admit those potential limits up front. Let me be clear, no single profession or individual specialist is capable of treating every potential malady that causes low back pain. Seeing an Interventional Pain Specialist with the experience to provide medical treatments, medication optimization, interventional treatments, and recommendations for chiropractic care as necessary is often the best way to integrate this potentially valuable pain therapy.
Acupuncture and Acupuncturists
High quality medical studies are limited for this treatment modality and techniques vary tremendously so it’s difficult to make any specific recommendations. However, I did find an interesting study titled: Battlefield acupuncture to treat low back pain in the emergency department. There were only 15 patients enrolled but they did find some improvement in numeric pain ratings among most patients. It isn’t clear how long the improvement lasted.
I don’t recommend seeking care from an Acupuncturist (or any “Alternative” provider) in isolation. There can be potentially life threatening causes of low back pain and obtaining a proper evaluation from a spine care doctor or pain specialist physician is the best way to identify these conditions. However, acupuncture can be a useful addition to your treatment regimen if coordinated with the appropriate physician sub-specialist.
Massage and Massage Therapists
As a treatment, massage appears to be most helpful in the short-term reduction of symptoms associated with low back pain such as muscle spasms. Many patients find this a useful adjunct to the other therapies discussed here. The largest limitation appears to be cost and access to quality establishments offering consistent services. If you find the right one and you have the time and resources – this can be a great way to spend an hour for your aching back. Just don’t expect a miraculous long-term resolution of your low back pain. As always, please consult a Pain Specialist Doctor to ensure that your condition is not something more serious.
Self-Professed “Experts” in Low Back Pain
It goes without saying, if you follow the advice of non-professionals or those without an appropriate depth of knowledge and a clear understanding of their limitations, your results are likely to be limited. A general rule of thumb is that anyone that claims they have “just the thing” or a “miracle” cure for all your low back pain woes should be approached with caution. There is likely no oil, no rub, no one medication, no single herb, no one physical activity, no special brace, and no “trick” to curing your low back pain quickly. You are better off sticking with a medical professional’s advice should you have prolonged or persistent low back pain limiting your activities and quality of life. Again, in some cases there may be a more serious underlying condition that needs to be diagnosed.
There are thousands of books and millions of articles on the topic of low back pain and degenerative disc disease. Given the shear amount of disability and cost associated with these conditions, it is a major public health concern. The occurrence of low back pain is on the rise and will continue into the foreseeable future. Considering the complexities of this topic, the potential impact on your life, your work, and those you love – you owe it to yourself to seek out a proper Spine Pain Specialist Doctor. It is my professional opinion that the best medical provider to seek out is one that has an extensive array of surgery-free interventional, diagnostic, and therapeutic back treatment options for you. In addition to optimization of your medications and coordination with adjunct therapies such as physical therapy and chiropractic care as indicated, you have the potential to substantially improve your low back condition. As an Interventional Pain Specialist, I look forward to providing you the benefit of my extensive training and experience in the treatment of your pain whether sciatica, discogenic pain, radiating pain, degenerative disc disease, spinal stenosis, arthritis, or other causes. Don’t hesitate to contact us today; we look forward to getting you on the road to low back pain relief!