Lower back pain

Whether you spend your day moving furniture or sitting in an office chair, you're probably no stranger to back pain. According to the Mayo Clinic, four out of five Americans suffer back pain at some point in their lives. It's an expensive proposition, costing the United States an estimated $100 billion a year.

Although problems can arise anywhere in the spine, the lower back is Pain Central. Low back pain is a major cause of disability and missed workdays. It's also among the most frequent complaints that send people to the doctor.

But even if your back is causing you excruciating pain, try not to despair. You shouldn't have to put up with the agony too long. Most acute back pain gets a lot better within a couple of weeks and goes away completely within a couple of months. With a little extra care, your back has an excellent chance to heal quickly.

What causes back pain?

To a large extent, modern medicine still hasn't solved the riddle of low back pain. In fact, doctors can determine a specific cause of back pain only about 15 percent of the time, according to two back pain experts writing in the New England Journal of Medicine in 2001. In most cases, a doctor could order multiple tests and still not be able to pinpoint a cause.

Most backaches are chalked up either to sprains or to strains in muscles or ligaments. These injuries -- often caused by heavy lifting or twisting -- won't show up on an x-ray or any other imaging technology, but the pain is no less real. A muscle spasm in the back -- caused by disk, joint, or muscle injury -- can also cause waves of intense pain.

Another common cause of back pain is osteoarthritis, which often causes pain after the cartilage that protects the joints between the vertebrae is worn down. Bearing heavy loads may result in bone spurs that press on a spinal nerve, and nerves in the disks themselves may also become irritated and cause pain.

Both osteoarthritis and excessive strain can also result in herniated disks, another possible source of back pain. Disks are flexible cushions that have a jellylike center and fit in between vertebrae to help absorb shocks. With advancing age or excessive strain, the cushions can wear thin. Eventually, the jellylike center of one or more disks can start to ooze out. This is called a herniated or "slipped" disk. In some cases, the center spreads out and presses against a nerve, causing considerable pain. However, most herniated disks are harmless. In fact, many people with no back pain have this condition and never know it.

Other causes of back pain are spinal stenosis (a narrowing of the tissue that covers the spinal column), spinal deformities, and fractures caused by osteoporosis. For a tiny minority of patients, back pain may signal a serious disease such as cancer, a bone infection, or a rare type of inflammatory arthritis. Finally, for some people, chronic back pain -- in the absence of any serious underlying disease or disorder -- may be linked to stress.

Is there a link between back pain and the emotions?

Yes, according to many researchers. In 2001 two German researchers interested in the connection combed through 900 studies on back and neck pain in a literature review and analyzed 37 in detail. Their conclusion: There's ample evidence of a link between back pain and the emotions. Not only were factors such as depression, dissatisfaction with work, and overall distress in daily life clearly associated with the onset of back and neck pain, but the same factors -- along with chronic stress -- were linked with back pain that turned into chronic pain and disability. Although these findings are controversial among some doctors, others are investigating the relationship between chronic tension and back pain.

"I have never seen a patient with pain in the neck, shoulders, back, or buttocks who didn't believe that the pain was due to an injury, a 'hurt' brought on by some physical activity," writes John Sarno, MD, professor of clinical rehabilitation medicine at New York University School of Medicine and an outspoken champion of a link between back pain and the emotions. He quoted a typical patient: "Ten years ago I was involved in a hit-from-behind auto accident and I have had recurrent back pain ever since." What this means, Sarno continued, is that "the idea that pain means injury or damage is deeply ingrained. But this is nothing less than a catastrophe for the American public, which now has an army of semi-disabled men and women whose lives are significantly restricted by the fear of doing further damage or bringing on the dreaded pain again."

Based on nearly 20 years of treating patients with chronic back and neck pain, Sarno has come to believe that most cases result from nervous tension, which temporarily constricts blood vessels and makes it hard for the cells to get enough oxygen. According to Sarno, chronic tension results in actual physiological changes in certain muscles, nerves, tendons, and ligaments, resulting in a "harmless but potentially very painful disorder" that he calls Tension Myositis Syndrome (TMS). According to Sarno, highly conscientious and self-motivated people are particularly prone to back pain, and anxiety and repressed anger can trigger muscle spasms. By unearthing and treating the sources of the tension and anxiety -- from job and marital troubles to caring for an ailing parent -- Sarno says, he has successfully treated patients who had previously suffered for decades from "intractable" back pain.

Who is at higher risk for back pain?

At least 80 percent of people will suffer from back pain at some point in their lives, so in some sense we're all at risk. Anything that causes wear and tear on the muscles, ligaments, bones, and disks of the back can bring on pain. People who constantly lift heavy objects or do a lot of bending or twisting often suffer as a result. At the other end of the spectrum, people who rarely get any exercise are also vulnerable to back pain, especially when they suddenly get a wild notion to move a couch or shovel snow from the driveway.

"In my experience, most of the time back injuries happen to the busy person who is out of shape and overworked and not paying attention to what he or she is doing," says Michael Potter, MD, of UCSF Medical Center. "If the pain turns into chronic pain, people are at risk of getting into a vicious cycle in which pain leads to depression, which in turn can make the pain worse and more difficult to treat. That is why it's important not to let pain fester for too long before getting some help -- and why doctors need to take pain seriously."

Besides strain and injury, other factors can increase the risk of back pain. Age also takes a toll -- most people first notice back pain after age 30. People in unfulfilling jobs or with unhappy home lives are also prime candidates for pain; according to Sarno, highly motivated individuals with repressed anger and anxiety -- often from shouldering overwhelming responsibilities -- fit into this category as well. And according to a report from the University of California at Davis, smokers are especially likely to develop back pain, possibly because cigarette smoking slows down circulation.

How can I control my back pain?

The good news about back pain is that most people quickly get better. Roughly one-third of all patients with a sudden episode of lower back pain improve greatly within one week, and two-thirds feel much better after seven weeks, according to a report in the New England Journal of Medicine.

For most people, the key to recovery is staying active -- within limits, of course. You may need to rest for a day or two, but lying around too long can weaken your muscles and increase your pain. Most people who try to return to their normal lives as soon as possible find that their ache gradually fades. Of course, some common sense is in order: If your job requires heavy lifting or other strenuous activity, you may have to take some time off to give your back a chance to heal.

While waiting for your back to recover, you may be able to ease the pain with aspirin, ibuprofen, or other over-the-counter pain relievers. A combination of cold and heat can also help. To reduce pain and inflammation, the Mayo Clinic recommends putting a store-bought ice pack (which can be used and refrozen over and over) or a home-made cold pack (a bag of ice wrapped in a cloth) on the sore spot soon after the pain first arises. Try the cold pack several times a day, 20 minutes at a time. When the pain starts to fade, 20 minutes with a heating pad can help loosen muscles and speed relief.

When should I see a doctor?

Most people with back pain can wait several weeks before they see a doctor, according to the Mayo Clinic. For many of them, the pain will probably disappear before they ever have to make an appointment. However, some people shouldn't wait that long. Lingering numbness or tingling in your limbs, for example, could be a sign of nerve damage.

In addition, if your pain doesn't show any signs of improving after 72 hours of rest, applying cold and hot packs, and taking pain relievers, it's time to see a doctor, according to the Mayo Clinic. If pain is treated in its early stages, it probably won't linger as long.

You should also see your doctor if you've had trouble with your back before, if you have a history of cancer or osteoporosis, if you've experienced unexplained weight loss of more than 10 pounds in the last six months, or if you're over 50.

Contact a doctor immediately if, along with your back pain, you show these signs of a serious medical problem:

  • a high fever that lasts for more than 48 hours
  • constant or intense pain (especially at night)
  • pain that spreads down one or both legs
  • loss of bladder or bowel control
  • stomach pain
  • weakness in the limbs or numbness and tingling in one or both legs

What kind of tests will my doctor order?

Your doctor can learn a lot about your condition simply by examining your back and asking about symptoms. If your pain has lasted for several weeks -- or if you show signs of a serious problem -- your doctor may need to take a closer look. Regular x-rays are not routinely used by doctors, because they can't show herniated disks and many other sources of back pain. If you show signs of nerve damage or have very severe symptoms that don't respond to physical therapy, anti-inflammatories, or other standard treatments, your doctor may order a high-tech imaging test such as a magnetic resonance image (MRI) or a computed tomography (CT) scan.

What is the treatment for back pain?

If your pain just won't go away, talk to your doctor about your treatment options. For mild to moderate cases, your doctor may prescribe muscle relaxants or prescription painkillers to help you feel more comfortable. If you have a herniated disk, he or she may suggest an injection of corticosteroids to calm inflammation of the nerves.

If back pain is a nagging problem, your doctor may also recommend specific exercises to ease your back pain and prevent future flare-ups. Exercise doesn't seem to help soothe sudden bouts of back pain, but it can definitely help control chronic cases, and it may be able to help prevent future injuries. According to recent studies, massage therapy, acupuncture, physical therapy, and chiropractic treatment can help as well. As always, it's best to take a new workout program slowly and let your body set the limits. You may also want to explore the research on the connection between back pain and chronic tension.

Back surgery has been overprescribed in the past, but it may still be the best remedy for a small minority of patients. If you have a herniated disk, if the pain shoots down to your legs, and if the pain has lingered for at least four to six weeks, your doctor may request an MRI to see what's going on. Based on those findings, he or she may recommend an operation to remove part of your damaged disk. Surgery may be necessary if you have a herniated disk accompanied by signs of nerve damage such as weakness and numbness. Surgery can also be used to remove a bone spur or correct a case of spinal stenosis, or narrowing. Be sure to discuss all of the pros and cons of surgery and all of your other options before agreeing to an operation.

What about chiropractors and physical therapists?

To rule out certain diseases or disorders that require medical care, the Mayo Clinic recommends seeing a regular doctor before trying chiropractic. For people who have a herniated disk or compression fracture, for example, manipulation of the spine could make things worse. If you get the go-ahead to try a chiropractor, find one who's willing to work with your doctor. That said, a chiropractor's hands-on approach may help relieve run-of-the-mill back pain, at least for the short term. The biggest barrier to chiropractic care is that it often isn't covered by health insurance.

For patients with low back pain, studies have shown that physical therapy is slightly more effective than medical care alone for reducing disability. One added benefit is that therapists emphasize what you can do to take care of yourself after the pain has been relieved.

How can I prevent back pain?

Once you've had an episode of back pain, the pain is likely to occur again. Your job is to make sure the attacks are as brief and as far apart as possible. If you lift heavy objects, let your legs, not your back, do the work. Get regular exercise, stretch before engaging in sports, and ask your doctor about exercises that can strengthen your back muscles. Avoid standing or working in the same position for too long -- try shifting postures at least every 20 minutes -- and keep your posture straight but relaxed. Sleep on a comfortable mattress. And if you smoke, stop. Finally, here's a recommendation from none other than the National Institutes of Health: Cut down on emotional stress that causes muscle tension.

Your back may hurt again, and it may not. Either way, it's up to you to keep your back as strong and healthy as possible. Back pain may be a fact of life, but it doesn't have to become a way of life.

Further Resources

American Chronic Pain Association (ACPA), P.O. Box 850. Rocklin, CA 95677 800-533-3231 http://www.theacpa.org

References

Deyo, R.A. and J.N. Weinstein. Primary care: Low back pain. New England Journal of Medicine. February 1, 2001. 344 (5) 363-370.

Mayo Clinic. Back pain. April 15, 2002.

NINDS Back Pain Information Page. National Institute of Neurological Disorders and Stroke, National Institutes of Health. www.ninds.nih.gove/health_and_medical/disorders/backpain_doc.htm

Sarno, John, MD. Mind Over Back Pain. Penguin Putnam, 1982.

Sarno, John, MD. Healing Back Pain: The Mind-Body Connection. Warner Books, 1992.

University of California at Davis. What are the lifestyle risk factors for low back pain? 2001.

Assessment and management of acute low back pain. American Family Physician. November 15, 1999.

Spinal Stenosis online factsheet, American Academy of Orthopaedic Surgeons

Christer, P.O. Carlsson, MD, PhD, et al. Acupuncture for Chronic Low Back Pain: A Randomized Placebo-Controlled Study with Long-Term Follow-up. The Clinical Journal of Pain 2001:17:296-305.

Hassenbring, M. et al. Psychological mechanisms in the transition from acute to chronic pain: over- or under-rated? DerSchmertz 2001 Dec. 15 (6): 442-7.

Hurwitz, E.L. A randomized trial of medical care with and without physical therapy and chiropractic care with and without physical modalities for patients with low back pain: 6-month follow-up outcomes from the UCLA low back pain study. Spine 2002, October 15; 27 (20): 2193-204.

Andersson, Gunnar B.J., "Epidemiological features of chronic low-back pain," Lancet 1999; 354 (9178): 581-585

Furlan, A.D., Brosseau L., et al., "Massage for Low Back Pain," (Cochrane Review). The Cochrane Library, Issue 4, 2002. Oxford: Update Software.

Cherkin, Daniel C., Eisenberg, David, et al., "Randomized Trial Comparing Traditional Chinese Medical Acupuncture, Therapeutic Massage, and Self-care Education for Chronic Low Back Pain," Archives of Internal Medicine, 2001;161:1081-1088.

Ernst, E., "Massage therapy for low back pain: a systematic review." Journal of Pain Symptom Management 1999;17:65-9.

Keeping Your Back Healthy at Work. MayoClinic.com.www.mayoclinic.com/invoke.cfm

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