Q: Our 82-year-old mother has changed drastically in the last six weeks. She went from being a swinging hipster to being practically confined to a wheelchair. And all for one reason: back pain. The doctors she has seen can't seem to see her as anything but an old lady. All they do is give her painkillers and other medications. We know different but we don't know what to do about it. What do you suggest?

A: The first step is to make sure a serious problem or cause for her painful symptoms has been ruled out. Before proceeding any further, it must be clear that there isn't a fracture, infection, or tumor at the bottom of her symptoms.

If she is indeed having what we call nonspecific low back pain, then the current recommendations for management are: stay active, exercise (prescribed by a Physical Therapist for each patient), manual therapy (including spinal manipulation by a Physical Therapist or chiropractor), and acupuncture. Pain control through medications has a role but it should not be the only treatment applied.

Studies show that older patients are more likely to have been to the doctor for low back pain before and given exercise recommendations. With subsequent visits, they are less willing to accept exercise as the answer and more likely to tell their doctor "exercise won't work for me."

Older adults are also more likely to complain of pain elsewhere (e.g., hip, knee). This may be a factor in why they are given pain relievers and other medications instead of following the current accepted guidelines for the management of low back pain.

When cognitive behavioral therapy (CBT) is suggested, there has been even more resistance than to exercise and less positive attitudes. CBT is a form of counseling aimed at changing attitudes and fears about movement and staying physically active.

Some people with chronic low back pain are so afraid of causing pain that they start to avoid movements and activities that might cause pain. This attitude is called fear avoidance behavior (FAB). And FAB has been shown in many studies to be reduced with cognitive behavioral therapy with the net result of decreased pain and improved function.

These attitudes about exercise and behavioral therapy among older adults represent a new challenge in the treatment of low back pain that may not have been recognized previously. Experts in this area recommend a thorough pain assessment and referral to appropriate specialists (Physical Therapist, acupuncturist, chiropractor, counselor) for patients who are willing to go. Education of the patient is often the key to compliance and response to treatment.

Reference: Gary J. McFarlane, et al. The Prevalence and Management of Low Back Pain Across Adulthood: Results From a Population-Based Cross=Sectional Study (the MUSICIAN study). In PAIN. January 2012. Vol. 153. No. 1. Pp. 27-32.

North Shore Physical Therapy provides services for Physical Therapy in Marblehead, MA.