In Singapore, we live in a society where east meets west. It’s perfect because we great the best of both worlds. Singapore General Hospital is ranked third in the world by Newsweek. As for eastern medicine, we have Beijing Tong Ren Tang 北京同仁堂, the largest producer of traditional Chinese medicine, here in Chinatown as well. The downside of having so many therapies available to us is how then do we choose? In this article, I share my completely biased (for evidence-based) suggestions for your low back pain.
Should I go to my GP for back pain?
GPs, or general practitioners, are primary care providers who are usually the first point of contact for non-emergency medical-related issues. According to SingHealth, a GP can treat fever, cold and flu, diarrhoea and vomiting, cuts and open wounds, abdominal pain, mild burns, as well as strains and sprains. Their ability to deal with many varied cases put them in a unique position to be an ideal first point of contact for your health issues.
Although general practitioners and family doctors have a big role to play in our healthcare system, they do not specialise in musculoskeletal health. As such, when it comes to strains and sprains, the amount of advice and treatments they can offer can be fairly limited. This is why it is not uncommon for doctors to refer cases on to physiotherapists.
Doctors prescribe medication
Being medical doctors, GPs de facto position is to prescribe medication. GPs commonly prescribe painkillers (e.g., NSAIDs) and muscle relaxants (e.g., Anarex) for back pain. For most acute cases, this can be enough. It is very possible that your pain can self-resolve with medication and some rest.
For those with chronic back aches, this is insufficient. Research has shown that NSAIDs (i.e., anti inflammatory drugs) and paracetamol are poor treatment options. In the UK, their national guidelines, NICE, specifically advised against paracetamol. First line treatments for low back pain include exercise and cognitive behavioural therapy. Research also actively recommend AGAINST complete rest.
GPs still have a role to play in managing spinal pain. Beyond prescribing medication, they can also coordinate care through referral to physiotherapists, x-rays, specialists, etc. Some insurance companies will also require you to have a referral letter from a GP before they would accept your claim for treatments such as chiropractic, physiotherapy, or TCM. However, they are unlikely to be the person to directly treat your back pain.
If you need GP services, you can use SingHealth’s Find a GP to find a clinic near you.
Can I go to a polyclinic for back pain?
Yes, but majority of back pain will not require you to go to a polyclinic. According to SingHealth, most back pain symptoms will improve on its own within 1-2 weeks, and only one in 10 cases will require medical attention. In other words, most back pain do not warrant a trip to the doctor’s office.
Should you choose to consult with a doctor (either private GP or polyclinic), you can expect them to perform an assessment to check for red flags. If there are no red flags, you will be treated with medication and/or receive a referral for physiotherapy.
Should I see a specialist for my low back pain?
The short answer? No, if you have not tried any reasonable amount of evidence-based conservative care. I specify evidence-based because if you were to try treatments are not unsupported by research, then statistically it is unlikely that you will get better. Therefore, there should be no expectations that you can improve.
When trying conservative care, you also need to commit to its “dosage” to get good outcomes. A few sessions of rehab or cognitive behaviour therapy is unlikely to make a difference because conservative care does take time. Your therapist will be able to advise you on how many sessions you require as well as the frequency of the sessions to get best results.
Remember, frequency also matters! Having too much time between treatment sessions can dramatically reduce the effectiveness of the treatment. This is true for all treatments, even outside of musculoskeletal care.
If you have digiliently tried a trial of evidence-based conservative for 12 weeks but you are still not showing signs of recovery, then a specialist visit may be worth consideration.
Which specialist is best for lower back pain?
Specialists are medical doctors who have received additional training in a specific area of medicine or surgery. To become a specialist, doctors would have to go for specialist post-graduate training and also pass the necessary accreditation examinations. There are 35 specialities and 10 subspecialties recognised by the Specialists Accreditation Board in Singapore.
Specialists that are commonly involved in the treatment of low back pain are Orthopaedic Surgery, Neurology.
According to the American Academy of Orthopaedic Surgeons, patients should try nonsurgical treatments (e.g., exercise rehabilitation) for 6-12 months before considering surgical options. Surgeries that can commonly performed for back pain include:
- Disc replacement: An artificial disc replacement (ADR) or implant is used to replace a damaged disc. Not as commonly performed for low back pain these days. Elon Musk swears by disc replacement it despite lack of compelling evidence to support the procedure.
- Discectomy: Removal of portions of a herniated disc in the spine to relieve pressure on spinal nerves. For some cases, minimally invasive spine surgery such as an endoscopic discectomy is possible. Procedure is performed with small incisions and can be discharged within the day of the procedure.
- Spinal fusion: Connect or fusing two bones in the spine to prevent them from moving. Makes the spine more stable and is used more in traumatic cases (e.g., car accidents) than for true low back pain cases.
- Laminectomy: Removal of the back arch of the vertebra called the lamina to relieve pressure on spinal cord or spinal nerves. Can also be done with endoscopic techniques. More commonly performed on patients with sciatica symptoms than those with low back pain alone.
All of the procedures above can also be performed by neurosurgeons.
Surgeons perform surgeries
Unless you are actively considering surgery, you probably don’t need to consult a specialist for back pain in the absence of red flags. All clinical guidelines list surgical procedures as last resort treatment for back pain, and most struggle to find compelling evidence to support its recommendation. The Lancet specifically labelled surgery for low back pain as “low-value care” that is contributing to skyrocketing medical costs.
There are also not many double-blinded, placebo-controlled trials investigating the efficacy of surgery for low back pain. Amongst the few that exists, substantial improvements can be attributed to placebo effects.
Is TCM good for back pain?
While not a medical doctor, TCM practitioners are often referred to as physicians. As such we have included them in this list. TCM, Traditional Chinese Medicine, is a popular treatment for back pain in Singapore. The TCM approach to back pain seeks to address issues such as qi and blood stasis, meridian blockages (e.g., kidney “deficiency”), dampness, etc. Examples of TCM treatments include acupuncture, tui na, cupping, and herbal medicine.
Most, if not all, of the treatments offered by TCM are passive in nature. In other words, they are treatments that are performed on you by a practitioner. This vastly differ from current evidence-based approach which highly favours interventions that allow patients to ownself-help-ownself.
Treatments like acupuncture and tui na can be found in several clinical guidelines. However, they are listed as second-line treatments after exercise and cognitive behavioural therapy. In other words, they are considered to be less effective.
Are chiropractors doctors in Singapore?
I feel like it is hard to publish this without mentioning chiropractors. To be clear, our stance has always been that chiropractors are not doctors. In fact, I don’t see the value of referring to us as one.
A lot of doctors in Singapore, on their websites, claim that it is their right to be referred to as a doctor in Singapore because of they graduated with a doctorate degree. This is, however, fallacious. The truth is that chiropractors are not recognised in Singapore and, by extension, a chiropractic doctorate is also not recognised. Furthermore, there is only one country, that is the United States, that issues doctorate degrees for chiropractic.
We standby that referring to chiropractors as doctors is a professional courtesy and not one that is readily given in Singapore.This professional courtesy does extend to dentists and veterinarians, many of whom do not hold a doctorate degree. Therefore, the doctorate qualification argued by chiropractors for their right to be referred to as doctors, is moot.
Do chiropractors really help with back pain?
Yes, but it really depends on which chiropractor you choose to see!
We have said this many times but bulk of the chiropractors we have in Singapore the crack-and-go type. Unfortunately, chiropractic adjustments alone are not enough to help a person recover from back pain.
Since our “exposé” piece about chiropractors in Singapore many of the chain clinics have started added exercise therapy into their package programme. This does increase the appeal of their offering and gives the appearance of a holistic recovery programme. However, the exercises offered are often basic stretches and simple exercises that are not meaningful for people living with back aches and soreness.
There are many treatment options available in Singapore and we understand that it can get very overwhelming. If you are experiencing low back issues and have no idea what to do about it, drop us a message below to learn more about how we can help.
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Based in Singapore, Square One Active Recovery offers treatments with a very big difference. With our evidence-based exercise approach, you can achieve your recovery goals in just 12 weeks. Not getting results from your chiropractor, TCM doctor or physiotherapist? Talk to us and find out how we can take your recovery to the next level.
Our goal? To make our own services redundant to you.
*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.