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How to manage back pain: Skip the scan

February 7, 2011

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At some point in our lives, four out of five of us will suffer from chronic back pain — and wonder what we can do to make it go away. It turns out that having a high-tech imaging test to diagnose the cause may do more harm than good, according to new guidelines released last week by the American College of Physicians.

“Routine imaging does not seem to improve clinical outcomes and exposes patients to unnecessary harms,’’ write the guideline authors. They cite statistics showing that despite increased spending on low back pain, we don’t report feeling any better.

“When it comes to dealing with back pain, more isn’t necessarily better,’’ says Dr. Steven Atlas, an internist at Massachusetts General Hospital who is familiar with the new guidelines. “Patients could benefit from having less.’’

The guidelines recommend an X-ray, CT scan, or MRI only for those with new back pain who are suspected of having a spinal tumor or infection, major traumatic injury from a fall or car accident, a spinal fracture from severe osteoporosis, or signs of a rare condition, called cauda equina syndrome, that causes nerve damage.

The vast majority of back pain sufferers should wait at least a month to see whether their pain abates before considering having an imaging test.

What’s the harm in having one earlier? First, you’ll get a small dose of radiation from CT scans and X-rays (though not MRIs), and radiation from imaging tests accumulates over a lifetime, contributing to cancer risk. Second, imaging tests often show evidence of arthritis or spinal disk abnormalities that doctors assume need to be treated with surgery.

But sometimes the problem found on the imaging test is the culprit for the pain, sometimes not. And most of the time, the body will heal itself without surgery. “It’s hard for physicians to sit on these results and not do something to fix the problem,’’ Atlas says. It’s hard, too, for those in pain to hear the words: Just give it time.

“We think our backs are never supposed to hurt but that’s not true,’’ says Atlas, who recalls having chronic back problems from lugging his kids around when they were young. Now, years later, he has occasional twinges, probably, he says, from arthritis setting in.

He tries to explain all this to his patients when they come to him with back problems. “It’s very rare that I need a diagnostic imaging test to tell me what treatment to recommend,’’ Atlas says. Usually he relies on taking a thorough patient history and a physical exam.

Most often, Atlas recommends that his patients rely on over-the-counter pain relievers like ibuprofen or acetaminophen to help them “muddle through’’ while their body heals.

Several weeks of physical therapy — which usually involves stretching and muscle building exercises — can also help relieve the pain, though therapists may need to experiment with different regimens, Atlas says, to see which one works best to relieve discomfort.

“It’s tough to find good evidence that any of these actually speed the healing process,’’ he adds. But they might be worth a try considering they’re nearly risk-free.

Simply walking, though, may be the best thing you can do to help relieve the pain, while lying in bed under the covers may be the worst.

So when is it smart to have an imaging test for chronic back pain?

“It may be a good time if your pain persists for more than a few months, and it’s impacting your life, not allowing you to fully function,’’ says Atlas. Say, you’re in pain every time you sit and you have a desk job, or you can’t lift anything over 5 pounds and you’re a construction worker.

DEBORAH KOTZ

Survey: Women should heed heart attack warnings

It’s an old story: A woman rushes into the emergency room clutching her chest, and the doctor grabs her husband assuming he’s the one having a heart attack. Well, now doctors are more up to speed when it comes to treating heart attacks in women.

Unfortunately, women still lag behind the times, failing to recognize their own heart attack symptoms or take them as seriously as they should, according to a 2009 American Heart Association survey.

Last week, the federal government launched a publicity campaign to educate women on the seven most common heart attack symptoms and the importance of dialing 911 when these symptoms occur: chest pain, discomfort, pressure or squeezing; shortness of breath; nausea; light-headedness or sudden dizziness; unusual upper body pain, or discomfort in one or both arms, back, shoulder, neck, jaw, or upper part of the stomach; unusual fatigue; breaking out in a cold sweat. D.K.

Colds and kids: Even medicine offers little relief

A few weeks ago, I was strangely relieved when my 10-year-old’s sore throat and fever turned out to be strep. At least, I figured, he can get antibiotics and will feel better in a day — which he did.

For colds, unfortunately, there’s little parents can do. The FDA recommends against giving children under age 4 any sort of over-the-counter cold remedy because of the risk of potentially life-threatening side effects. And experts say even for older kids, the cough suppressants and decongestants don’t do much to relieve symptoms.

“There’s just not much parents can do to relieve symptoms or prevent their kids from getting colds,’’ said Dr. Ronald Turner, a professor of pediatrics at the University of Virginia School of Medicine. What about washing hands frequently? It might help in a school or day-care setting, Turner said, “but it has a limited impact overall, and it doesn’t prevent colds from spreading at home.’’ D.K.

For football fans, heartache after a loss is real

Take note, fans of the losing team in last night’s big game. Findings published last week by the journal Clinical Cardiology show that a Super Bowl loss paralleled an uptick in heart attacks and deaths over the next two weeks in the losing team’s city.

Dr. Robert Kloner, a cardiologist at Good Samaritan Hospital in Los Angeles, and his colleagues counted heart-related deaths that occurred on the day of the 1980 Los Angeles Rams Super Bowl loss and for 14 days after, and heart deaths after the 1984 Super Bowl win by the Los Angeles Raiders.

In men, the 1980 loss was associated with a 15 percent increase in heart deaths compared with expected deaths for that time of year, whereas in women, there was a 27 percent increase. The risks were greatest in seniors — an extra 2.6 deaths per 100,000 people over age 65 per day.

The 1984 win was followed by a drop of less than 1 percent in heart deaths. D.K.