On day one, she couldn’t move. Juana was a thirty-six year old friend of mine. Juana had a strong, Latin personality. She took pride in everything she did and was very disciplined and measured with everyone that she met. She had been on a health kick recently, and started doing an 80-day fitness program. In the middle of doing a chest press, she felt a sudden pain in her lower back. It crippled her to the point where she had to stop immediately. Juana was a pretty healthy person. She exercised regularly, drank rarely, never smoked. She also did Zumba once or twice a week, yoga routinely.
She described the pain as a shock. She had difficulty standing up and walking. She didn’t have any radiating pain down her legs, but she felt locked up in her own skin. As a mother of two, she was usually very active, but her whole itinerary halted after this. She came to the clinic, desperate for medication. She took a shot of a strong anti-inflammatory, a steroid, and began taking oral muscle relaxants hoping that it would be enough to get her back on her feet.
Back pain is something that almost everyone will experience at least once in their lifetime. The statistics from the NIH suggest upwards of eighty percent of people will experience this. It is the most common cause of job related disability. It can be a mild nuisance, where a person simply wakes up with a stiffness. It can also be quite severe, where it is incapacitating. While the majority of low back pain will resolve on its own, without treatment, within a thirty day period, in our immediate gratification culture, an hour is too long. Initial therapies will usually include over the counter medications, like Ibuprofen or Naproxen. Heat or ice may also help, but realistically time is what will ultimate fix this.
On day two, she was still in tears. The muscle relaxants gave her a dry mouth and the Ibuprofen she was taking was giving her gastritis. She looked a hot mess. Her hair was disheveled, her clothes were wrinkled and didn’t match. It looked as if she basically grabbed whatever she could comfortably put on. Fortunately for her, an osteopathic medical student was available, and he was able to manipulate her sacrum and spine to the point where she was at least walking again. As the day progressed, however, she gradually regressed back to her slouched posture and by day’s end, she was in pain again.
Low back pain is defined as acute when it lasts less than four weeks. In cases where low back pain persists longer than that, imaging may be appropriate to evaluate for things such as disc herniation, disc degeneration, and spinal stenosis. In addition, if back pain presents with additional symptoms, like urinary symptoms, chest pains or shortness of breath, fever or neurological symptoms, like numbness or radiating pain, imaging may be necessary much sooner.
On day three, Juana began to worry. It was more of the same. She couldn’t get out of bed. And while her overall pain had improved, she was still stiff as an ironing board. This had never happened to her before, where her pain was so unrelenting. The student continued to treat her. She even sought out a chiropractor for good measure, but nothing seemed to help her. And while she was making progress, she seemed to appear broken. That resilient spirit that Juana had, where she could overcome any adversity, seemed to be failing.
In treating low back pain, medications can help, but physical therapy can be tremendous in reducing the time needed to get back to normalcy. Spinal manipulation is a great resource in treating pain as the need for pain medications can be reduced with therapy. Ice and hot packs may help in pain management. In severe cases, spinal injections may also be an option.
Certain risks can increase the chances of having back pain. Increasing age and low fitness level can predispose a patient to low back pain, along with weight gain and pregnancy. Genetic predisposition and occupational risk are possible risks that patients generally have limited control over. Finally, pain is a subjective variable, and patient’s with low pain thresholds or have psychiatric comorbidities may be more difficult to treat.
By day five, she was more desperate than usual. She wanted an MRI. She wasn’t going to take no for an answer. She threatened to go to the emergency department if she didn’t get what she wanted. “I don’t feel better,” she said, despite the fact that her posture had definitely improved from the time that I started evaluating her. I told her that by the time an MRI was approved by her insurance, her back pain would be gone by then. Somehow, I was able to convince her to hold off on going to the ER for one more day.
In cases where back pain fails to progress, surgery can be an option. If imaging reveals a problem and conservative measures fail, neurosurgical options become available. This is a limited option, as results are never guaranteed, and pain symptoms may actually worsen. The results are operator dependent, so it’s crucial that the right doctor is consulted.
A miracle happened on day six. Juana woke up and began her routine completely forgetting about her back. She put on her makeup and made herself look presentable for the first time in almost a week. And something happened to her face. She was actually smiling. After the “I told you so” look I gave her, she said “I still want an MRI.” While this event may have broken her spirit momentarily, it was back in full force, as she was more stubborn than ever.
By: Dr. Juan Borja
Original post: https://yourdoctordad.com/broken/