What is back pain?
Everyone's back pain is different. For some people, back pain involves mild
pain (pain that is bothersome, aching, sore). For other people, back pain
involves severe pain (pain that hurts all the time, even when resting).
Most doctors refer to back pain as acute (generally severe, but short-lived),
subacute or chronic (long-lasting or occurring often). Acute back pain
usually lasts from one to seven days. Pain may be mild or severe and
occasionally may be caused by an accident or injury. About 80 percent
of all back pain is acute. Subacute back pain usually lasts from seven
days to seven weeks and usually is mild; occasionally it's severe. This
pain generally is unrelated to other illnesses you may have. About 10
to 20 percent of all back pain is subacute. Chronic back pain usually
lasts more than three months and maybe mild or severe. It may be related
to other illnesses you may have or may have no identifiable cause. About
five to 10 percent of all back pain is chronic.
Incidence and risk factors
Back pain is one of the most common health problems in the United
States, yet its cause is generally unidentified.
It is estimated that 50 to 80 percent of adults have had back pain
at some time and that 10 percent of all Americans have back pain in
a given year. Back pain can occur at any age in both men and women.
However, it may occur slightly more often in women beginning at middle
age, probably due to osteoporosis.wever, it may occur slightly more
often in women beginning at middle age, probably due to osteoporosis.
Anatomy
The back is held upright by muscles attached to the backbone. Doctors
often refer to the backbone as the spine, spinal column, or vertebral
column. The backbone isn't one long bone, but actually 24 separate
bones called vertebrae. These 24 vertebrae are stacked one on top of
another to form the backbone.
The points where two vertebrae or bones fit together are called joints.
They make it possible for the spine to move and turn in many different
directions. Look at the backbone and find the discs located between
each vertebra (see figure 1). These discs are made of cartilage, which
is a soft, elastic material. Discs act as cushions, or shock absorbers,
much like the shock absorbers in your car. Their main job is to protect
the joints from wearing out. Most joints contain a slippery substance
called synovial fluid that keeps them moving smoothly.
The spinal cord is very important because it transmits electrical
signals between the brain and the nerves in your legs, arms, back, and
other parts of your body. The spinal cord runs through a hole in each
vertebra of the upper and middle parts of your backbone, much like a
piece of string through a beaded necklace. The space it runs through
is called the spinal canal. At times, a message might signal pain or
discomfort. The pain signal is an important one, because pain tells
you that some part of your body needs attention.
A serious injury to the neck or upper back runs the risk of damaging
the spinal cord, causing paralysis of the parts of the body below the
injury. It should be noted that the spinal cord is not present in the
lower part of your backbone. Here the spinal canal contains a sack of
nerves, the cauda equina.
Your backbone, with all its parts, cannot hold itself upright. It
needs strong muscles, tendons, and ligaments for support. Muscles help
you move or hold your position (see figure 2). Tendons fasten muscles
to bones. And ligaments stretch from one bone to another to hold bones
together.
Immediate medical attention
If your back pain is accompanied by any of the following, see a doctor
today:
Weakness
or numbness in one or both legs
Pain going down one
leg below the knee
Back pain from a
fall or injury
Back pain accompanied
by fever without flu-like aches
Pain that continues
to interrupt sleep after three nights
Or back pain that
remains after six weeks of home treatment
Causes and effects
Causes
Back pain can be a symptom of arthritis or many other conditions;
this material is intended for anyone who has back pain, regardless
of the cause.
Anything that puts pressure on your back muscles or nerves can cause
pain. Any illness or damage to your spine also can cause pain. The cause
of most acute back pain is unknown, but probably is due to minor strains,
sprains and overuse. Emotional stress may add to the pain, especially
since it slows the rate of recovery. Other possible causes of back pain
are listed below.
Ruptured intervertebral disc
This may be the most painful, yet easiest condition to identify. A
ruptured or herniated disc is one that bulges into the spinal canal,
pressing on the nerve roots (see figure 3). This causes the nerve roots
to become irritated. A disc can rupture after bending over and lifting,
or it may occur for no apparent reason. A ruptured disc may cause back
pain and muscle spasms, but a more common symptom is sciatic pain.
This is severe pain spreading down one leg and often into the foot.
Sometimes it is the only symptom of a ruptured disc. A ruptured disc
usually can be detected by a physical examination alone. Sometimes
a procedure such as a myelogram, computerized axial tomography (CAT)
scan, or magnetic resonance imaging (MRI) is needed to confirm the
diagnosis and determine if surgery is necessary.
Spinal stenosis
In spinal stenosis, the spinal canal becomes narrowed. This squeezes
the back nerves and puts pressure on them. It is this pressure
that causes the back pain. Numbness, pain and weakness in the legs
also can occur. The most common symptom of spinal stenosis is pain
that worsens when walking and subsides when sitting down.
Osteoarthritis
Osteoarthritis is just one form of arthritis that can cause back pain.
It breaks down the cartilage (soft, elastic material) that cushions
the spinal joints and other joints in the body (see figure 4). Lower
back pain can become more intense when osteoarthritis affects the hips
or the knees. Osteoarthritis also can directly affect the spine, causing
muscles, tendons, or ligaments to become strained, which can lead to
back and/or neck pain.
Ankylosing Spondylitis
Ankylosing spondylitis is a form of arthritis causes the joints in
the spine to become stiff and swollen. In time, stiff joints can
fuse (grow together). The most common symptoms are pain and stiffness
in the buttocks and lower back (particularly in the morning) that
continue for more than three months.
Injury or accident
Have you ever moved a piece of furniture that didn't seem too heavy,
only to feel pain in your back the next day? Have you ever stretched
for something that was just a little out of your reach and felt a twinge
in your back? Many back injuries are caused by an unexpected twist
or sudden motion. This usually results in muscle strain.
With either an injury or accident, severe muscle spasms usually last
48 to 72 hours. They generally are followed by days or weeks of less-severe
pain. It usually takes two to four weeks to heal completely from a mild
back injury. It could take from six to 12 weeks if there are strained
ligaments or if the strain is more severe. Severe back injury from a
fall or accident may require hospitalization and a longer recovery period.
Osteoporosis
Osteoporosis is a type of bone disorder
that causes bones to become thin and weak due to calcium loss. Fragile
bones, especially those bones in the spinal column, can break more easily,
and there is an increased tendency for this to happen in older women.
Osteoporosis also contributes to compression fractures, or spinal fractures
in which the vertebrae become flattened. Falls, lifting heavy objects
or moving the wrong way can result in a compression fracture.
Rheumatoid Arthritis
Rheumatoid arthritis causes any joint to become stiff, painful and
swollen. It can affect the neck but almost never the joints in the
lower back.
Polymyalgia Rheumatica (PMR)
Polymyalgia rheumatica is a rheumatic disorder that causes muscle
pain, aching and stiffness in the neck and shoulders, lower back,
thighs and hips. It can last a few months or many years. Most people
experience severe stiffness in the morning.
Fibromyalgia
People with fibromyalgia feel pain and stiffness in muscles and tendons,
especially in the neck and upper back. The pain can last for weeks,
months or years. The symptoms may disappear by themselves. This condition
often is related to sleep problems, poor conditioning or an old injury.
Paget's Disease
Paget's disease is a type of disorder in which the calcium in the
bone spreads unevenly. The bones most commonly affected are in
the lower back, pelvis, tailbone, skull and long bones of the legs.
Back pain may be a symptom, but most often there are no obvious
symptoms. Paget's disease usually is discovered on an X-ray or bone
scan done for reasons other than pain.
Other conditions
Sometimes pain felt in the back actually originates elsewhere in the
body. Such problems may include:
Prostate
trouble in men
Problems with reproductive
organs in women
Kidney diseases,
such as an infection or kidney stone
Diseases of the intestines
or pancreas, such as cancer or a blockage
Cancer that has spread
to the spine
Multiple myeloma,
a form of cancer of the bone and bone marrow
Curvature of the
spine
Rarely, a tumor on
the spinal cord
Effects
Back pain is one of the leading causes of disability and time lost
from work. Recent studies indicate that direct medical costs for lower
back pain approach the $24 billion mark each year, with indirect costs
(work loss, compensation) reaching approximately $35 billion for a
combined total of nearly $60 billion.
Diagnosis and evaluation
Health care team
It often is difficult for doctors to find the exact cause of back
pain, especially since there are so many possible causes. If the cause
is unclear, your family doctor may suggest that you see an orthopaedist,
rheumatologist, neurosurgeon, neurologist, physiatrist or other medical
specialist for diagnosis.
Diagnosis
Regardless of what type of doctor you see, there are some things you
can expect your doctor to do during your visit. Your doctor first
will ask you a number of questions, the most common of which are listed
as follows:
What are
your symptoms--that is, what aches or pains do you have?
Exactly where is the
pain?
Where is the pain the
most severe?
When did the pain begin?
How long have you had it?
Did something specific
cause your back pain, such as an accident or injury?
What home treatments
have you used?
Were you under any
additional stress when the pain began?
Do you have any other
health problems?
What kind of work do
you do?
In what types of recreational
activities do you participate?
Think about these ahead of time so you can answer them easily. You
also may have questions you'd like to ask the doctor. As you think of
questions at home, jot them down and take them to the appointment.
Next, your doctor will give you a physical exam. During the exam,
the doctor may perform any of the following:
Observe
your muscles and joints
Ask you to sit and
lie down
Ask you to move your
back in different positions
Observe and feel
the area of most pain
And/or check to see
if other areas of your body are tender or painful (such as the kidneys,
intestines or other organs)
If the doctor can identify the likely cause of your back pain at this
point, no further tests will be needed.
Diagnostic tests
If the doctor needs more specific information, he or she may ask you
to undergo one or more of the following lab tests:
X-ray
Studies show that in many cases of routine back pain, X-rays may not
initially be necessary. However, the signs and symptoms will determine
what type of study should be done. In certain cases, X-rays might indicate
that pain is due to:
Injury
in one or more of the back bones
A tumor in the spine
A deformity in the
spine
Ankylosing spondylitis
CT Scan
Only a few people with lower back pain need a CT (computerized axial
tomography) scan. If your doctor advises one, a special machine takes
an X-ray scan of the area. A computer turns this scan into a three-dimensional
view of the back. This helps the doctor see if there is a ruptured
disc that can't be seen on regular X-rays. Other conditions that a
CT scan can help detect are spinal stenosis, tumors and infections
of the spinal cord.
MRI
MRI (magnetic resonance imaging) is another way to make very clear
pictures of parts of the spine. The MRI does not use X-rays or radioactive
dyes. It can provide dearer pictures of soft tissues such as muscles,
cartilage, ligaments, tendons and blood vessels, in addition to bone
structure.
Myleogram
During a myelogram, a special liquid dye called contrast medium is
injected into the spinal canal. X-rays are then taken of the area.
The contrast medium can make problem areas show up more dearly on the
X-ray. A doctor may order a myelogram to detect problems such as spinal
stenosis or spinal cord tumors. If surgery is being considered, particularly
for a person who has had a serious back injury, many neurosurgeons
will require a myelogram beforehand.
Bone Scan
During a bone scan, a very small amount of radioactive liquid is injected
into a vein and concentrates in the bones for a short time. A special
radioactive detecting machine then will scan the area of concern to
produce a picture. Occasionally bone scans are done to look for damage
or tumors in the bones themselves. However, back pain is rarely due
to diseases of the bones.
Electrodiagnostic studies
Electrodiagnostic studies are used to help confirm the presence of
nerve compression in the spine. An electrodiagnostic study consists
of two tests. One is an electrical test, which is designed to study
nerve conduction. In this test the nerve is given an electrical stimulation,
and the speed of the impulse is measured. The other test is a needle
test called an electromyogram, or EMG. The purpose of this test is
to study the muscles for primary disease or for the effect of nerve
compression on the muscle. The compression is especially seen in herniated
discs or spinal stenosis.
Blood tests
If your doctor orders blood tests for you, a laboratory technician
will carefully draw a small amount of blood from a vein in your
arm, which then will be tested in the laboratory. Any one of the following
blood tests may beordered:
Erythrocyte
sedimentation rate (sed rate)
Hematocrit and hemoglobin
White blood cell
count
HLA B-27 test
Chemical profile
(SMAC)
Your doctor may order other blood tests. Ask for an explanation of
the tests.
Management and treatment
Treatment
More than 85 percent of people with lower back pain improve with minimal
treatment in a matter of days. However, if back problems persist, doctors
generally prescribe one or more of the following treatments: proper
exercise, rest, heat and cold, posture training, weight loss, stress
management and relaxation exercises, medication, spinal manipulation
and/or surgery.
For some back conditions, the doctor may refer you to another specialist
such as an orthopedist, rheumatologist, physiatrist, physical or occupational
therapist, psychologist, psychiatrist or surgeon.
Exercise and therapy
For many people, the key to a healthy back is proper exercise. Some
exercises are designed to strengthen your back and stomach muscles,
while other exercises are designed to improve your posture. A 30-minute
aerobic conditioning program three times a week is ideal for overall
fitness. Walking and/or water exercise are highly recommended for most
people with back problems.
The right kind of exercise program may help keep your back problem
under control. It can make it easier for you to continue doing your
daily activities. You may need to take a break from vigorous exercise
if it makes your back pain worse. The exercises shown in figures 5-10
and in the movies may help strengthen the back or improve posture. Ask
your doctor and physical therapist which exercises you can do to relieve
back pain, stay fit, and prevent injuring yourself again.
The Arthritis Foundation and the University of Washington disclaim
any liability for loss, personal or otherwise, resulting from the exercises
presented here. If you have any leg pain or other evidence of nerve
injury, consult you physician before beginning exercises. DO NOT carry
out any exercise that makes your back pain worse!
Rest
The most common treatment doctors recommend for severe back pain is
bed rest. Different people require different amounts of rest. Usually,
two to three days of staying in bed, except to go to the bathroom,
will be enough to ease your back pain. You may want to ask the doctor
if special pillows or devices are necessary. Sometimes these aids give
additional support to your neck, back or feet.
Hot and cold treatments
Many people have found that hot and cold treatments help relieve back
pain. You might try both to find out which works better for you.
Heat relaxes muscles and soothes painful areas. There
are many ways to apply heat. Some people like hot showers or baths,
while others prefer using heat lamps, heating pads or warm compresses.
If you have arthritis, heating your muscles first might make it easier
for you to do back exercises. Be sure not to fall asleep while using
heat. Cold has a numbing effect. This often helps relieve pain. You
might try one of these methods for applying cold:
an
ice bag
a large ice cube
used to massage the area
a frozen package
of vegetables (peas work best)
a commercially made
cold pack.
Be sure not to leave ice on after the skin becomes numb. This could
lead to localized frostbite. Do not use cold if you are especially sensitive
to it or have decreased circulation or sensation. Read the pain management
article for more information about heat and cold.
Posture training
If poor posture is a factor, then posture training may help relieve
your back pain. During posture training, an occupational or physical
therapist will teach you healthier ways to sit, stand, sleep and lift
objects.
Techniques for good posture:
When sitting:
Sit in a firm chair with armrests to relieve pressure in your
back and shoulders.
Keep your upper back straight and shoulders relaxed. Keep stomach
muscles pulled in, and maintain the proper curve in your lower back.
You can do this by tightening your stomach and buttocks. Some people
are more comfortable sitting with the back of the chair at a 15- to 20-degree
angle. A small cushion behind the lower back to maintain the natural
curve of the back also can be quite helpful.
Keep your knees slightly higher than your hips.
Use a footstool or book under your feet if necessary.
Keep your feet flat on the floor or other surface.
Don't sit for a long period of time. Stand up every now and then
to stretch tight muscles and give them a chance to relax.
When standing:
Stand with weight equal on both feet.
Avoid locking your knees.
Ease tension in your back by placing one foot on a footstool.
If you stand for long periods of time, wear flat or low-heeled
shoes.
Keep your back straight by tightening your stomach muscles and
buttocks.
When sleeping:
Lie on your side with your knees bent.
If more comfortable, place a pillow between your knees while sleeping
on your side.
If you sleep on your back, ask your doctor or physical therapist
if placing pillows under your knees would help your lower back pain or
make it worse.
Use a firm mattress.
Body mechanics
To keep good posture while in motion is to use good body mechanics.
In lifting, this means that the object lifted is held close to
the body and that lifting is done with your legs. The normal back curves
are maintained, the legs lift the load. Avoiding twisting your
back, particularly when carrying a load, is also important for good
body mechanics. Move your feet, do not twist your torso.
When
bending down to lift an object, bend with your knees instead of your
back.
Hold the object close
to you.
Straighten your legs
to lift the object.
Get help with an object
that is too heavy.
The type of shoes you wear can also affect your posture. High heels
may put more stress on your lower back by changing your posture. You
might find it more comfortable to wear low or flat heels. Cushioned-soled
shoes also provide "shock absorbency" for your spine.
Diet
Don't be surprised if your doctor recommends weight loss as one way
to reduce your back pain and improve your general health. The best
way to lose weight is with a balanced diet along with regular exercise.
Be sure to avoid fad diets or fast weight-loss programs.
Medications
If your back pain is not relieved using other forms of treatment,
your doctor may prescribe medication. The medication chosen depends
on the back pain. For example, medications called analgesics can help
relieve pain. Other medications called muscle relaxants can help relax
tight muscles. If your back pain is caused by arthritis, your doctor
can give you medication that will reduce inflammation as well as relieve
your back pain. The most common medications prescribed are called nonsteroidal
anti-inflammatory drugs (NSAIDs). These medications can reduce inflammation
without working like cortisone, the body's anti-inflammation steroid
hormone. Aspirin and ibuprofen are NSAIDs. Other NSAID medications
are prescribed when needed.
Learn all you can about your medications by asking your doctor or
pharmacist questions such as those listed below.
Questions to ask the doctor about medications:
What
will the medication do?
How long will it
take before I notice results?
What is the name
of the medication? Is there a generic brand?
Are there side effects
I should know about?
How should I take
the medication (i.e. before or after meals, with or without food,
etc.)?
How often should I take
the medication?
What should I do if
I forget to take a dose at the specified time?
Let your doctor know if you are taking other medications. Sometimes
certain medications cannot be taken together.
Surgery
People with sciatica or spinal stenosis often benefit from surgery.
A few people with tumors within the spinal canal require it. Other
than that, few people with back pain need surgery. Most people can
be treated successfully with rest, exercise and medication. Surgery
does not always work for many common kinds of back pain, and it is
difficult to know who will be helped and who will not. An orthopedist
can help you decide if a back operation is necessary. It is recommended
that you also seek a second opinion.
Unproven remedies
It often is difficult to be patient when you are suffering from chronic
back pain. You might be tempted to try unproven treatments. A treatment
that promises "a quick cure" or "miraculous relief" can
sound wonderful. But remember, these unproven treatments usually are
expensive and will do nothing for you. The sensational successes you
hear about usually are illusions. They even may be harmful and often
keep you from getting the medical care you really need. If you hear
about a new treatment, discuss it with your doctor and get his or her
advice.
Coping
Strategies for coping
Stress, poor posture, lack of exercise and being overweight all can
contribute to back pain. Luckily, these variables can be controlled,
and their effects lessened.
Relaxation training
Many people relieve their back pain by doing special breathing or
muscle relaxation exercises. If you have chronic back pain, check with
your doctor to see if relaxation training can help.
Weight loss, exercise, and diet
Think about the extra pounds people carry every day due to their being
overweight. This puts added pressure and strain on the back and stomach
muscles, causing those muscles to stretch and weaken. Weak back and
stomach muscles cannot support the back properly. Poor posture can
shift your body out of balance. This forces only a few muscles and
joints to do all the work. Without proper exercise, muscles become
weak and tire easily. Exercise is necessary to keep the back strong
and limber.
A good conditioning (aerobic) exercise program led by a trained instructor
can be particularly helpful. An effective program includes a warm-up
period; about 30 minutes of aerobic activity (exercise that results
in a sustained heart rate of l00 or more beats per minute); isolated
muscle group work (including abdominal muscle toning); and a cool-down
period. Over a period of time, the rewards of regular aerobic workouts
can include a slimmer waistline and healthier back.
Asking for help
If you and your doctor decide that stress and tension are making your
back pain worse, your doctor might recommend that you see a psychologist,
family counselor, psychiatrist, clergyman or other mental health specialist.
They can teach you how to better handle your stress.
Stress
Every day of our lives is filled with some kind of stress. In fact,
any situation can cause stress such as work, personal relationships,
raising children, paying bills, the death of a loved one or a new experience.
Even very happy occasions such as a family wedding, birth of a new
baby or family vacation can be stressful. For many people with back
pain, the greatest stress comes from unwanted changes in their lives
caused by the pain itself.
People react to stress in different ways. Some may feel tired, sleep
poorly, overeat, or feel irritable. Some clench their jaw. Others tighten
their neck and shoulders. Still others get a headache or an upset stomach
when they are tense.
If your pain is acute, you may be able to reduce your stress by reminding
yourself that you just need to wait until the pain disappears. However,
if your pain has become chronic, you may need to take a good look at
what you want to do, what you need to do and what you actually can do.
Try to set some new goals that are more realistic, taking into account
your pain and limitations. Talking to understanding friends and family
members about your new goals and abilities can make this task easier.
Many people tighten their back muscles when they are worried or tense.
This can make existing back problems worse. Take a minute now to think
about what happens in your own body when you worry or get tense. Do
you think stress is affecting your back? Since we cannot remove everyday
events from our lives, the key to managing stress is changing how we
react to daily living. Think about how you react to everyday events.
What methods do you have for relaxing and releasing tension from daily
stress?
Tips for managing stress:
First, learn to relax. There are many ways to relax and relieve
stress without using drugs or alcohol or without spending a lot of money.
Take a warm bath.
Take 10-15 minutes to sit quietly and breathe deeply.
Get involved in your favorite hobby or learn a new hobby.
Start an exercise program.
Take a short nap.
Find a comfortable place for light reading.
Meet a friend for a walk or a chat.
Eat regular meals and take time to enjoy them.
Plan fun activities with your family or friends.
Do something nice for yourself.
Learn relaxation techniques and set aside time to practice them.
Take a stress management class.
Learn to accept what you cannot change instead of feeling constantly
frustrated.
Try laughing instead of taking things too seriously. Take a positive
outlook.
Learn to manage your time effectively.
Get professional help with problems or stresses that continue
to bother you.
