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The Dose Transcript for January 25, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. For many Canadians, recurring or persistent low back pain is the bane of their existence. Painful, debilitating for them, and for many front line people like me, frustrating to assess and treat. Frankly, a lot of the advice we have given traditionally has been unhelpful or even counterproductive. But we can do better if we follow the science, the evidence. So this week, we are asking a question millions across Canada likely ask themselves and the health care system every day, how can I manage chronic back pain? Hi, Brenda. Welcome to The Dose.

BRENDA LAU: Hi, Brian.

BRIAN GOLDMAN: How did you get to a place where you actually like treating people with back pain?

BRENDA LAU: Honestly, it's not just back pain. It's just pain in general. Solving someone's problem where it's feeling like so stuck is so satisfying. So that's where we come from. It comes from all the way back from childhood. But that's another story altogether.

BRIAN GOLDMAN: And that makes you the perfect person to talk to. But before we begin our conversation, can you give us a hi, my name is? Tell us what you do and where you do it. Just adlib.

BRENDA LAU: My name is Brenda Lau. I am an anesthesiologist by trade, but most is pain specialty. And that's a formal specialty now in Canada. I also wear a couple of other titles, like the medical director of Change Pain Clinic here in Burnaby, B.C., and I'm a UBC clinical associate professor.

BRIAN GOLDMAN: Let's start with some of the basics. What's the difference between, say, an acute back strain and chronic back pain?

BRENDA LAU: So acute and chronic, generally from the point of view of definitions, is around that three to six month mark that transitions from what is called acute into chronic. And then it's all about the symptoms as well. Generally, if you can resolve in that time frame, they will call that acute in less than six months.

BRIAN GOLDMAN: Can you describe the profile of someone at risk of developing chronic back pain?

BRENDA LAU: The average person with low back pain is in their working years. So somewhere between 25 years old to let's say 55. And typically, it's someone who's actually been a lot of sitting around type of desk job, administrative, and maybe not as active. Another profile maybe at risk is higher smoking, maybe not so healthy habits and eating a lot of fast food. Maybe sugars on board. Not having good sleep is a typical profile of developing low back pain, let alone having some sort of funny strain. Maybe a twist. Of course, there's more catastrophic things like motor vehicle accidents, falls and cancer, but that's another whole list of injuries.

BRIAN GOLDMAN: How does chronic back pain manifest differently in men versus women?

BRENDA LAU: I would say in general, low back pain is pretty consistent, actually, with men and women. Low back pain has a lot of different contributors, if you will. It comes from fascia, muscles, joints, ligaments and discs. But how someone presents, how they respond and how they actually show their back pain, that's where it's different between men and women, I find. So for example, men often just try to push through it in such a way that it kind of gets to the critical point where now, let's say you can't walk. And that's a little bit of a more extreme. Whereas a lot of women will sound the alert a lot earlier, sometimes at the risk of feeling that they are, you know, sounding the alert too early. So it's a little bit of that extreme between the genders that I see.

BRIAN GOLDMAN: Looking at people at risk, there is this one area that I want to just cover off very quickly, and that has to do with people who are older, beyond their working years. My sense, based on what I see as an emergency physician, is that I see an ever increasing number of older people in their 70s and 80s coming in with severe, chronic low back pain. And they may or may not have a history of workplace injuries, for instance, that might typify some of the people who are in that younger age group that you described. Can you talk about that?

BRENDA LAU: I'm going to address it in, let's say, these three ways. The first is going to be a group of people in which their lifestyle has been quite sedentary, really haven't worked the muscles and the bones. And so now we're seeing an increased risk of osteopenia, osteoporosis you see when people say, I used to be this tall and now I feel like I'm a lot shorter. So those kinds of reasons where it's affecting directly the musculoskeletal system because the bones aren’t strong and therefore, it now starts affecting the joints. And the joint pains of facets of the spine are the typical, like the spondylosis, anterolisthesis. These big words are really targeting this shift in the joints and the position of the bone vertebras. There's another group in which, of course, now it's a little bit more sinister, things like cancers or even benign. Tumours. And back pain is one of those reasons that show up. There is a fewer of those cases which is related to things like infection, but there's also the presentation of inflammatory disorders. And some of these kind of rheumatology disorders, they take up to like 10, 20 years to kind of show itself. So even though there might have been small things like I feel a bit tired and stiff in the morning 20 years ago, it kind of reveals itself, let's say, a couple of decades later. So that's what you're seeing in that group. And then a third group is, as I mentioned before, is a little bit along the side of, you know, there's some strain or feels like there's aches and pains, but there's more of the noetic causes of feeling alone, the isolation, needing to connect, like I need to be valued and cared for, but they don't know how else to express it. And interestingly, there is studies that show the real crossover between depression and pain in general, especially neck and back. So I'm not saying that depression causes back pain, but not only does it aggravate it, but it will show up in some somatic symptoms in ways because the person is looking for some help in different ways, and back pain can get exacerbated.

BRIAN GOLDMAN: Brenda, when I was looking at the most recent literature, I saw a reference to a term again and again that I'd like you to talk about, and that is non-specific low back pain. Can you speak to that for a moment?

BRENDA LAU: We don't have a very good categorization system. Canada and most other healthcare systems uses an ICD code classification, which is an international classification of these various diagnoses. And we're now on iteration number 11, and not all countries have adopted that yet. But there really hasn't been terminology that really speaks to the mechanisms. We're getting closer and closer. So that's why you have a bit of an umbrella term when we say non-specific mechanical, because what it's trying to point at is that there are some features of the spine, the ligaments, tendons, deeper muscles, even fascia that play a role. But we also know the imaging, MRI, CT scans, x rays, whatever you see there, they don't correlate to the intensity noted by the back pain. This general term is essentially trying to catch a number of causes that are known to be triggers, but you can't exactly pinpoint it because it's usually not just one.

BRIAN GOLDMAN: It's really interesting that you just cited MRIs and CT scans, because I can tell you, and I'm sure you know what I'm about to say, as an emergency physician, patients with back pain want or maybe even expect me to order that CT scan of the spine or MRI of the back. In general, what do you think of that?

BRENDA LAU: It's the half and half of understanding of where the value of those scans come in and how you interpret them. So that's what I mean by half and half because it's reassuring, obviously, to have the imaging to make sure you don't have what is called the red flags. So typically, we are looking to make sure we've got no new fractures, underlying infection and tumour. These are the red flags that could be treated with surgery, antibiotics and other interventions. The non-red flag conditions, as I mentioned before, is kind of this umbrella term of non-specific mechanical back pain, will never equal the findings on the MRI. We have thousands of patients in studies where they have no back pain at all, but they've randomly taken them to get a scan, and they have the same findings as someone who has back pain, and in fact, back pain of very high intensity. So as a pain specialist, I utilize the image to help confirm what I've already understood through the history, physical examination, and more importantly, through diagnostic testing. Like with video branch blocks for facet joints, for example, the image does not tell you intensity, but the response to a diagnostic test does help us understand what the mechanism is. So as an emergency physician, when it's being asked, I understand it's coming out of sphere most of the time, especially if it's something brand new. Of course, it beholds us to make sure that we're not dealing with red flags. But when it's of a chronic nature of which there's been no new injury and no new changes in medical status like, you know, taking a high dose of steroids that would put them at risk of something new, it makes no sense to do repeated scans where, it is my experience, they show very little change that would either merit any change in treatment or the use of this examination. It would not change management at all.

BRIAN GOLDMAN: To the points that you've been raising, all excellent points. As an emergency physician, I'm not coming at this as a complete novice. We take a history and do a physical examination, and we're searching for evidence or suspicions. Anything that would increase our suspicions of those red flags. So if they've got a history of cancer, or if they're suddenly developing severe back pain in their older years, the years when they're more likely to have cancer, that might be a red flag. You know, a relatively young person, a person in their mid-teens suddenly developing back pain, that's a red flag. Somebody who uses intravenous drugs or who is prone to urinary infections that go on to sepsis, they can develop an infection in the middle of their back. That's a red flag. So we are taking a history, but we have to manage the expectations of patients who think that there's a magic answer in every MRI or CT scan.

BRENDA LAU: That's it. And I 100% agree with all the points you made right there. And that's why emergency physicians are such superb frontline diagnosticians at that level of the red flags. And that's why what's another aspect of what you just said there is that and unfortunately, because many people are seeking pain management at the emerge department, their expectations are mixed. Instead of just ruling out, like you just mentioned, the red flags, it's now the expectations of more of the chronic management. And it's using the acute pain diagnostic process to deal with chronic, and that's not appropriate.

BRIAN GOLDMAN: So let's get to the point then. How should we be treating chronic back pain?

BRENDA LAU: Chronic back pain is a spectrum of treatment. I always like to start with prevention first. It's always easier than trying to cure it in the end. And so with preventative factors, we're looking at gut health. We're looking at reducing inflammation, whether reducing smoking, ensuring that hypertension is controlled, ensuring that you've got proper gut and nerve system supports, ensuring that you've got excellent sleep, because that's the most important reparative time frame and toolbox that we've got in our bodies for healing. And of course, now looking at things like our lifestyle, our sedentary and what level of sitting that we're doing, because that literally is the new smoking. What it does to our back muscles, the hip flexors, all of those things need to be really looked at. What we need to do is rehabilitate, retrain the way those muscles are working. And that's where the conservative therapy with our excellent physiotherapist, chiropractors, exercise physiologists, dedicated trainers can get people back on their feet. But I always say it doesn't matter if it's a medication or if it's exercise or a needle. If you're not seeing your results, increase in progress over kind of a period of three to four months, maybe even up to five months, if you're not seeing that, you really need to start looking differently.

BRIAN GOLDMAN: There is a relatively new treatment that treats the psychological dimensions of chronic pain, let's put it that way, in addition to the physical dimensions, and it's called pain reprocessing therapy. What can you tell us about that?

BRENDA LAU: As we know, there are changes that occur in the nerve system from the brain to the spinal cord and the spinal cord out to the nerves that reaches all parts of the body. And within that nerve system, think of that like your operating system in a computer. And just like it needs upgrades or it has changes when you add updates to it, that's what happens to the nerve system when an injury occurs. It starts to make the communications in the system different. And so that different could be good and could be bad, meaning it could be bad in the sense that if it's quantification of just the pain, the fear of the pain, the kind of interpretation of pain impact on you, your family, it can now lead to a whole host of decisions in life that could range from I'm just going to lay in bed for eight hours to I'm not going to move because it's going to injure me. So these kinds of thought processes could now lead to other changes in the body that aren't so healthy. The changes in the nervous system can also be good too. In other words, that when you now are responding to injury, one could actually reinterpret these signals, understand that it's reassuring, start to actually desensitize, if you will. Meaning that use of movement, use of mind words, use of ways that you eat, all these things now, it actually becomes an impetus for positive change.

BRIAN GOLDMAN: How effective is it?

BRENDA LAU: Yeah, it's very effective. Again, I'm looking at the subset of people in which we have ruled out all of the sinister, immediate red flags, and we're looking at the capability of mobilizing one's behavior, movement, eating, sleeping, smoking cessation, the habits that go into, including the mind over matter, words that are often coming into our heads in reaction to a flare up or some sensation. And so as we practice this, it changes how we breathe, it changes everything about how we see our response of that pain, and it reduces the fear response. And in that direct way, you reduce the stress hormone release. In that way, you reduce the inflammation caused by high stress hormones that are released.

BRIAN GOLDMAN: I want to go back to my emergency physician experience for just a moment. And it may be that I'm seeing a very specific subset of the people you're talking about, the people who actually come to the emergency department, because I can tell you that we have kind of a boilerplate approach to prescribing medications for patients. I would say that in virtually every encounter with somebody who has kind of a worsening of their chronic back pain, that we're going to prescribe them something. And it's typically anti-inflammatories like naproxen and muscle relaxants like Flexeril. And based on what you've just said, are we doing more harm than good?

BRENDA LAU: Initially, the intention is good. It's to give you something to empower you, you take away, and even on its own, has it in itself a placebo effect that by your authority as the physicians providing this treatment, someone will at least start to feel that they've got something in their hands they can do something with. But long term wise, using anti-inflammatories for chronic back pain doesn't help. And we know that. And the long term side effects of those do in fact cause more harm. Kidney damage, gastric issues is two of the main things. And so one of the biggest things is understanding that it's not just tissue pain and inflammation. There are these noetic factors of fear. There could be some… like the question is why now? Why now is that flare up occurring and why now are you seeking emerge help? And it'd be interesting when people ask that question. There are other factors that bring that on board. For example, a fight with your spouse, a pressure at work, a number of these things. And I'm not saying that that is the cause of the back pain, but because it drives behaviours. Remember what I said about pain reprocessing and the words in our head create the direction in which we respond to that pain. So if we now feel that a lot of things are against us and we're not in a good position, all of a sudden, now even this soreness or small tension now becomes in fact quite disabling. And so just treating that along with the medication, without giving the power of these other tools, we are then doing a disservice to our patients because then it's only just about this pill.

BRIAN GOLDMAN: There's a question that I have to ask you, because a lot of the people we see in the emergency department with chronic back pain ask about chiropractic treatments. I'm assuming that there's some analogy between, you know, the quick fix, the hope for a quick fix from a pill and the hope for a quick fix from a chiropractic adjustment, but I want your thoughts on that.

BRENDA LAU: So I have great respect for my chiropractic colleagues. But there is a range, just like there is a range of physicians and their skill sets. And so those in which are not just focussed on a physical manipulation, but actually focus on the bigger picture of meaning, mental well-being, the emotional well-being, even just that connection at times is enough to create that rapport that supports that person's healing. So that's one point. The second point, just going to adjustment per se. For example, there are times when the facet joint is really acting up and that back spasm is in reaction to that. And so an adjustment in those areas can make all the difference for some people. But if they don't do the work to look at how the body is moving or in position or not in well position, it's just going to reoccur. So just like a medication, if you're only relying on this external tool, you will never be able to break the cycle of what caused that back pain in the first place.

BRIAN GOLDMAN: There's no guarantee that chronic pain will go away. But in your experience, in what percentage, roughly speaking, do these principles at least help them manage their own pain?

BRENDA LAU: Brian, pain is a call to action, and it's a call to action that most people can ignore. So over the last 10 years, we've seen over 600,000 episodes of care. And I would say 30% of those are low back pain in general. And because we personally take a layered care approach looking at, you know, like the body like an onion, you've got to look at fascia, muscles. If you take a look at those layers like that, then not only one, you don't miss things that are hidden, but the second is that you can now take the time to build the body back up when it has not worked as well as you want it to. And in those percentage of people, I have seen… so our initial study is about five years ago showing about two thirds were generally well, done well with just the early layers of care where we integrated our allied health team like our physio and kinesiology rehab team with the basic medical therapies. That was outstanding. But it's about another third that do not respond to that combination that now needs a little bit more advanced work. So in general, taking these larger principles, we know a great majority of people can curtail the recurrence of these back pain flareups. And then those who already have back pain, I tell you, it already changes their fear response and the whole sympathetic response, so that not only it's the pain that gets improved, sleep is improved, their overall movement with ease is improved. Their eating, their bowels, their gut digestion, those things are improved. And that's all because of reducing these stress hormone releases. This combination method does work.

BRIAN GOLDMAN: This is a great optimistic note on which to end our conversation. Doctor Brenda Lau, thank you so much for sharing your expertise and wisdom on managing chronic low back pain.

BRENDA LAU: Thank you, Brian.

BRIAN GOLDMAN: Dr. Brenda Lau is an anesthesiologist and pain specialist. She's the co-founder and medical director of the Change Pain Clinic in British Columbia. Here's your dose of smart advice. Back pain is an extremely common ailment for many adults. It can start as a strained back, which may recur. When the pain lasts 12 weeks or longer, we call the condition chronic. Acute back pain is due to things like injury or inflammation. With chronic back pain, the acute injury or inflammation has likely disappeared. At that point, the pain is likely due to abnormal processing of pain signals inside the nervous system. It may be perpetuated by some surprising factors such as emotions and the bacteria in your digestive system. The pain can affect the ability to do work and sleep. Chronic back pain requires a thorough history and physical by a qualified health care provider. The purpose of the assessment is to uncover lifestyle factors that perpetuate and even worsen the pain, and to look for what health care providers refer to as red flags for serious causes of back pain, things like slip discs as well as infections and cancers that involve the spine. CT scans and MRIs of the spine are used mainly to rule out red flags. Treatments for low back pain include physical therapies to improve core muscle strength and range of motion. Psychological approaches can help people manage their pain and return to previous activities. In general, the goal is to increase physical activity. Bedrest is not generally recommended because it makes the problem worse through deconditioning. Medications can reduce low back pain acutely, but in the long run, generally do more harm than good. Opioids, once a mainstay, should only be prescribed for severe acute pain at the lowest dose and for the shortest possible time. There are several things you can do to reduce symptoms and help prevent further episodes. These include being physically active, maintaining a healthy body weight, quitting smoking, getting good sleep, being engaged in social and work activities, and making adjustments in the workplace. The key is to put you in charge of managing your pain so you're less dependent on health care providers. These approaches may not eliminate chronic back pain, but they can reduce pain significantly. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How can I manage chronic back pain? - Transcript

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