Back Pain

Back Pain

Oh, my aching back!

You bend over to tie your shoe or pick up your four-year-old. There goes your back. Sometimes it's just a twinge. Other times the pain is so acute that you need to lie down immediately.

Everything you do affects and is affected by your back -- the way you sit in your office chair, how you drive, how you eat, how you sleep. Any extra weight you may be carrying also puts a strain on your back.

Back pain may be constant and dull, located in just one area, or striking and acute, spreading from the back down into the legs. The latter's cause may be a slipped or ruptured disc: cushions that sit between the spinal bones (vertebrae).

Detailed Description

The tissues in the back include bone, muscle, tendons, ligaments, and soft tissue. Injuries and disease of any of the tissues can cause back pain. Of the many causes, perhaps the best known is the "slipped disc" (herniated intervertebral disc). Though it accounts for a small percentage of patients with back pain, it may "pinch" (compress) a nerve, causing sciatica -- pain radiating down the back and/or side of the leg, numbness or tingling in the leg and foot, and/or muscle weakness in the leg.

Back pain can be caused by a local injury, such as a deep bruise or ligament tear. It can also result from a widespread condition, such as rheumatoid arthritis. In most patients, back pain is a recurrent or ongoing condition.

To reduce the chance of acute back pain or strain, it's helpful to know the good mechanics of back movement, as well as functional support for those who sit for extended periods.

How Common Is Back Pain?

As much as 80% of the population may suffer from back pain during their lifetime. It is estimated that at any one time, more than 5% of adults may have back pain.


Possible Underlying Causes

Injuries and disease of any of the back tissues can cause pain. The following can all be causes: infections, fractures, and tumors of bone; sprains and strains of muscles and ligaments; inflammation of spinal joints; compression of the spinal cord and nerves.

Triggers of Back Pain

A poor body position as one is doing heavy lifting is a well-known trigger for back pain. Sitting for prolonged periods seems to predispose some people to back pain, as well. Back pain is also more common in pregnant women.

Diagnosing the Underlying Cause

While back pain often can be fleeting or mild, in other instances it may be a symptom of an underlying disease or disorder. Some of these disorders have certain characteristic symptoms in addition to back pain.

The following is a partial list of conditions that may include back pain among their symptoms. The presence of back pain should not lead you to conclude that you have a more serious disorder. You should not attempt to diagnose yourself with a medical condition, even if your symptoms match the characteristics of a certain disorder. If your symptoms concern you, the best thing to do is to seek medical advice.

Back pain unaccompanied by other symptoms may be due to:

  • Disc herniation. Displacement of the cartilage disc between two vertebrae causing irritation to spinal nerves and/or the spinal cord. Usually causes a severe lower back or neck pain that increases with movement, heavy lifting, sneezing, coughing, and straining on the toilet. Pain radiating from the low back, through the buttock, and down the leg can occur, as can numbness and muscle weakness in the leg. Arm or hand pain, numbness, and tingling may also be present if the disc herniation is in the neck.
  • Osteoarthritis. Deterioration of the cartilage and bone that lines the joints. This becomes more common as one ages, and causes pain and stiffness of one or more joints.
  • Obesity. Being overweight (20% or more above your recommended weight) demands more support from the spine and back muscles, which can result in sprain or strain.
  • Osteoporosis. Loss of bone mass associated with a loss of calcium and a change in bone structure. It may result in backache, more easily fractured vertebral bones, loss of height, and stooped or hunched posture.
  • Spinal stenosis. Narrowing of the spinal canal due to bony overgrowth. Characteristically the symptoms are similar to disc herniation and include back and leg pain, and weakness and numbness in the legs and back that is worsened by walking.
  • Sprain/strain. Swelling with pain and tenderness in the affected joint/muscle.
  • Spinal fracture.

Diagnostic Procedures

The physician will take a history and perform a physical examination. Based on the findings, other tests may be used, including:

  • X-rays
  • CT (computerized tomography)
  • MRI (magnetic resonance imaging)
  • Blood tests

Goals of Treatment

The general aim is to relieve pain and restore function. For acute, uncomplicated back pain, the general approach is conservative. Short-term rest (for one or two days), pain relievers and anti-inflammatory medicines, gentle and gradual exercise, and a careful return to regular movement are the mainstays of treatment.

Treatment Options

Short-term rest, gentle exercise and stretching, ice or gentle heat, and finding comfortable positions are all useful treatments. Medication is not the only element of back care. Yoga, physical therapy, and chiropractic may also be employed. Medicines for underlying conditions such as arthritis may help, and occasionally surgery is an option.

Drugs most commonly used

For uncomplicated back pain, first choices include:

Second choices

The selection of a prescription medication for back pain depends on the nature of injury and the length of time you will be taking the drug. Using these medications requires special care. Some may cause drowsiness and should not be used before driving or operating heavy equipment, and alcohol should be avoided with all the following medications:

Chiropractic

Chiropractors use spinal manipulation to treat musculoskeletal problems, particularly back problems. Chiropractic is the most popular form of alternative medicine in the United States.

In 1994, an expert panel of 21 M.D.s and two chiropractors reviewed the research on treatment of back pain for the U.S. Department of Health and Human Services' Agency for Health Care Policy and Research (AHCPR). The panel's report, "Guidelines for Acute Lower Back Pain," endorsed chiropractic as safe and effective. A few of the studies the panel cited:

  • In an analysis of 25 well-designed studies that compared rest versus chiropractic for treating back pain, a researcher in Santa Monica, Calif., found that chiropractic patients were 17% more likely to report recovery within three weeks. For sciatic pain, recovery within three weeks was 10% more likely with chiropractic. [1]
  • California researchers surveyed a large group of back-pain sufferers treated by either family M.D.s or chiropractors. In the M.D. group, 22% said they were "very satisfied" with the results. But 66% of those receiving chiropractic reported being "very satisfied" -- three times as many. [3]

Yoga

Yoga provides gentle stretching and strengthening exercises that can help relieve back pain. In England, a survey of 3,000 yoga students noted that 98% of those with back pain found yoga had helped. [4]

Yoga classes are offered in most communities. Check your local YMCA, health clubs, or phone-book listings. If you mention your back problems, the teacher can recommend poses that help, and modify those that might strain your back. If any posture causes pain, stop doing it.

Tai Chi

Tai chi, a popular form of exercise and martial art in China, involves slow, graceful, dance-like movements. The typical routine contains 50 to 100 moves -- it takes a few months to learn, and a lifetime to master. Its gentleness makes it particularly suited for rehabilitating muscle and bone injuries, including bad backs. In one study, part of a group of 51 people with chronic back pain were told to live their lives as usual. The rest took a weekly 90-minute tai chi class that included 15 minutes of home practice every day. After six weeks, the tai chi group reported significantly less back pain. [5]

Alexander Technique

The Alexander technique is a program of postural re-education. The trainer closely observes how you stand, sit, and move, and suggests subtle adjustments in your posture.

Stress Management

Chronic stress, tension, and anxiety cause chronic muscle tension that can aggravate back pain. At a San Diego clinic, researchers gave psychological tests to 82 back-pain patients. Compared with a control group free of back pain, the back-pain sufferers had more stressful lives; notably, problems at work. As their work difficulties increased, so did the severity of their back pain. [6]

There are many activities than can reduce stress: exercise, yoga, tai chi, biofeedback, having a fish tank, deep breathing, laughing, meditation, gardening, spending time with friends, spending time in nature, playing or listening to music, and volunteer work. Decide on an approach that appeals to you, and do it regularly.

Herbs

Devil's claw root (Harpagophytum procumbens) is a traditional folk remedy for musculoskeletal pain, including bad backs. German researchers recently confirmed its effects by testing it on a group of 118 people whose chronic low back pain required them to take pain-relieving drugs frequently. In addition to their usual drugs, some test subjects were given a placebo and others devil's claw root (800 mg three times a day). Two weeks later, those in the drug-placebo group reported just one pain-free day. But the drug/herb group reported nine. [7]

Acupuncture

In one study, half of a group of back-pain sufferers received acupuncture at all the back-pain points, while the other half were needled at only a few back-pain points. After 10 months, 11% of the group receiving acupuncture at only a few points reported improvement, compared with 58% in the fully treated group. [8]

1 Shekelle, P.G., et al. "Spinal Manipulation for Low-Back Pain," Annals of Int. Med. 117:590, 1992.

2 Anderson, R., et al. "A Meta-Analysis of Clinical Trials of Spinal Manipulation," Journal of Manipulative and Physiological Therapy 15:181, 1992.

3 Cherkin, D.C. and F.A. MacCornack. "Patient Evaluations of Low Back Pain from Family Physicians and Chiropractors," Western J. Med. 150:351, 1989.

4 Steefel, L. "Yoga Therapy and Low-Back Pain," Alternative and Complementary Therapies 2-97.

5 Bhatti, T.I., et al. "Tai Chi as a Treatment for Chronic Low Back Pain: Randomized, Controlled Study," Alternative and Complementary Therapies 3-98.

6 Williams, R.A., et al. "Contribution of Job Satisfaction to the Transition from Acute to Chronic Low Back Pain," Archives of Phys. Med. and Rehab. 79:366, 1998.

7 Chrubaski, S., et al. "Effectiveness of Harpagophytum procumbens in Treatment of Acute Low Back Pain," Phytomedicine 3:1, 1996.

8 Coan, R.M., et. al. "Acupuncture Treatment of Low Back Pain," American Journal of Chinese Medicine 8:181, 1980.


Preventing Back Pain

  • Don't slouch. Sit up straight. Mom was right: good posture helps prevent back pain. Poor posture places stress on your back, making you more prone to discomfort.
  • Your sitting posture is even more important. Pressure on the discs between the bones in your back is higher when you're sitting than when you're standing. It's no coincidence that those at highest risk for back pain -- truck drivers and office workers -- have jobs that demand sitting for extended periods. If you work sitting down, try to sit less and stand more. Take breaks. Get up at least once an hour and walk around.

    Speaking of sitting, does your desk chair provide lower back support? If not, use a lumbar (lower back) pillow or cushion. The back of your chair should lean back slightly. Keep your back against it and avoid leaning forward. If you work at a computer, adjust the height of your chair and keyboard so your forearms and thighs are parallel to the floor and your eyes are level with the top of your monitor. Your back and legs should form at least a 90-degree angle. Keep your shoulders down and back.
  • When lifting, use your legs, not your back. No matter how light or heavy the object, lift it properly. Keep your back straight -- don't bend over and lift with your back. With bent knees, pick up the object in the midline of your body, hugging the object as close as possible. Avoid twisting as you lift. When you set the object down, always bend your legs, never your back.
  • When rising from a seated position, remember that you're lifting your body weight. Use your legs, keeping your back as straight as possible.
  • If you're heavy, consider losing some weight. Even a few extra pounds can add enough stress to your back to cause pain. Weight loss often brings dramatic relief.
  • Wear sensible shoes. Flats are the way to go, not high heels. While fashionable, high-heeled shoes shift your natural center of gravity, which can strain your back.
  • In a car, consider using a pillow or rolled-up towel for added low-back support.
  • Exercise also helps prevent back pain. In a study of Los Angeles firefighters, those who were the most out of shape had the most back pain. Fitness was protective.

Self-Care Measures

  • Get back to normal activities as soon as possible. Doctors used to recommend long-term rest, but no longer. British researchers analyzed 10 studies involving 3,222 back-pain sufferers who were told to either rest in bed or stay active. Bed rest showed no benefit. In fact, those who rested recovered more slowly. Now doctors generally advise no more than a day or two of bed rest before you return to normal activities.
  • Invest in back-sparing devices. Special furniture, pillows, and other products can bring relief from back pain.
  • Get more exercise. Avoiding it is one of the worst things you can do for your back, according to a 1994 report by the federal Agency for Health Care Policy and Research (AHCPR). The AHCPR specifically recommended such exercises as walking, swimming, and cycling.

Today, most back-pain experts encourage a return to exercise as soon as comfortably possible. Walking is often recommended, as anyone can do it without special training or clothing, but do whatever you enjoy. Try to exercise daily for about 30 minutes. Stay away from anything that stresses your back, for example, high-impact aerobics, racquet sports, and most team ball games.

When to Call the Doctor

Consult your doctor if:

  • You have fallen from a significant height and you have back pain
  • Back pain is accompanied by abdominal pain
  • Pain is excruciating
  • You have loss of limb movement
  • You feel numbness or tingling in the arms or legs
  • You have loss of bowel or bladder control
  • Your ability to walk or sit is seriously affected
  • Back pain does not disappear after one to four weeks of rest

Websites & Other Resources

American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870

Arthritis Foundation
National Office
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800

National Institute of Arthritis and Musculoskeletal and Skin Diseases Clearinghouse
1 AMS Circle
Bethesda, MD 20892

Osteoporosis and Related Bone Diseases-National Resource Center
1150 17th St., NW, Suite 500
Washington DC 20036
Phone: 202-223-0344 or 800-624-BONE (2663)
TTY: 202-466-4315
Email: orbdnrc@nof.org

Wheeless' Textbook of Orthopedics

Sources & Further Reading

Books

Balch, James F. and Balch, Phyllis A. Prescription for Nutritional Healing. Garden City Park, NY: Avery Publishing, 1997.

Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W.B. Saunders, 1996.

Fauci, Anthony J. et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds. Stamford, CT: Appleton & Lange, 1998.



Articles

Anderson, R. et al. "A Meta-Analysis of Clinical Trials of Spinal Manipulation," J. of Manipulative and Physiological Therapy, 15:181, 1992.

Balagu'e, F, Dutoit, G, Waldburger, M. "Low Back Pain in Schoolchildren. An Epidemiological Study." Scand J Rehabil Med. 20(4):175-9. 1988

Bhatti, TI et al. "Tai Chi as a Treatment for Chronic Low Back Pain: Randomized, Controlled Study," Alternative and Complementary Therapies, 3-98.

Cady, LD et al. "Strength and Fitness and Subsequent Back Injuries in Firefighters," J. Occup. Med., 21:269, 1979.

Cherkin, D.C. and F.A. MacCornack. "Patient Evaluations of Low Back Pain from Family PHysicians and Chiropractors," Western J. Med., 150:351, 1989.

Chrubaski, S. et al. "Effectiveness of Harpagophytum procumbens in Treatment of Acute Low Back Pain," Phytomedicine, 3:1, 1996.

Coan, R.M. et. al. "Acupuncture Treatment of Low Back Pain," Am. J. Chinese Med., 8:181, 1980.

Edgar, MA. "Backache." Br J Hosp Med. 32(6):290-301. Dec 1984.

Fast, A, Weiss, L, Ducommun, EJ, Medina, E, Butler, JG. "Low-back Pain in Pregnancy. Abdominal Muscles, Sit-up Performance, and Back Pain." Spine. 15(1):28-30. Jan 1990.

Mantle, MJ, Greenwood, RM, Currey, HL. "Backache in Pregnancy." Rheumatol Rehabil. 16(2):95-101. May 1977.

Sarkin, TL. "Backache in the Aged." S Afr Med J. 51(13):418-20. Mar 26, 1977.

Sarno, JE. "Psychosomatic backache." J Fam Pract. 5(3):353-7. Sep 1977.

Shekelle, P.G. et al. "Spinal Manipulation for Low-Back Pain," Annals of Int. Med., 117:590, 1992.

Shiple, BJ. "Treating Low-Back Pain," Phys. and Sportsmedicine, 8-97.

Steefel. L. "Yoga Therapy and Low-Back Pain," Alternative and Complementary Therapies, 2-97.

Waddell, G, Main, CJ, Morris, EW, Venner, RM, Rae, PS, Sharmy, SH, Galloway, H. "Normality and Reliability in the Clinical Assessment of Backache." Br Med J. 284(6328):1519-23. May 22, 1982.

Waddell, G. et al. "Systematic Review of Bed Rest and Advice to Stay Active for Acute Low-Back Pain," Br. J. Gen. Pract., 47:647, 1997.

Williams, RA et al. "Contribution of Job Satisfaction to the Transition from Acute to Chronic Low Back Pain," Archives of Phys. Med. and Rehab., 79:366, 1998.

 

 

 

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