Understanding Back Pain
You’re lifting groceries — or bending to tie a shoelace — when all of a sudden your back goes out. Or maybe you’re just sitting at your desk when your lower back starts aching. Backaches can come on suddenly or gradually and their cause can be maddeningly hard to pinpoint. “Most people try to blame their pain on one thing they did or didn’t do, when it’s usually the buildup of a number of factors that is responsible,” says Sheila A. Dugan, MD, associate professor of physical medicine and rehabilitation at Rush University Medical Center, in Chicago.
“For a vast number of people, back pain comes from multiple sources, and we’re just not sure why it hurts so much,” says orthopedic surgeon Howard S. An, MD, director of spine surgery at Rush. What’s more, what works for one person may have no effect on another, making the search for relief a byzantine journey from orthopedist to chiropractor, rheumatologist to physiatrist (a physician specializing in rehabilitation.
In the process Americans spend $85.9 billion a year on coping with back pain, according to a recent article in the Journal of the American Medical Association. Approximately 80 percent of us have at least one episode, making it the second most-frequent health complaint after the common cold.
“The irony is, most back problems can be prevented,” says Stephen H. Hochschuler, MD, chairman of the Texas Back Institute, in Plano. “If you stay in shape, watch your weight, and are careful about how you move and use your body, you have a good chance of avoiding or lessening the severity of back problems.” Use the following pages to see whether your habits could be setting you up for a backache — and to find out what you should do if pain strikes.
The Anatomy of Your Back
Problem: You strained a muscle or tendon, or sprained a ligament. Bands of ligaments and tendons hold the vertebrae in place and attach muscles to the spinal column. A strain or sprain is the most common cause of back pain. Torn muscles and tendons are known as strains; the same kind of injury to a ligament is a sprain.
Why it hurts: Think of your abs and back muscles as support wires for your spine. If you have bad posture and you rely on the wrong muscles to hold up your spine, they can become fatigued. Playing sports incorrectly or when you’re not warmed up can also cause this. Something as minor as bending over to pick up a toothpaste cap can also stress weakened tissues, pulling the back out of alignment and causing a painful back spasm. When you tense up or hunch over to protect the injury, you can make the spasm worse. The trigger can also be psychological rather than physical. If you are stressed, that tension can make muscles tighten, pinching nerves and setting off a spasm.
Problem: A disk is getting worn, compressing a nerve. Disks (rounds of fibrous tissue between vertebrae) function as shock absorbers for your back. More than 50 nerves branch off from the spinal cord, and when they are squeezed or irritated, pain results.
Why it hurts: When disks wear as a result of aging, osteoarthritis, degenerative disk disease, or injury, the jelly-like center herniates (or bulges), which can press on nerves (a condition colloquially known as a “slipped disk”). One possible result is sciatica (pain involving the long sciatic nerve, which runs down from the lower back through the buttocks and legs and into the feet).
Problem: One or more vertebrae are cracked or out of alignment. The spinal column has 24 vertebrae, stacked one on top of another. The five lumbar (lower-back) vertebrae carry the weight of the entire torso, making that part of the spine the most frequently injured.
Why it hurts: The usual suspects: excess weight, pregnancy or congenital conditions such as scoliosis (sideways curvature) or lordosis (exaggerated arch to lower back) stress weak muscles and joints, especially the sacroiliac joint (where the lower spine connects to the pelvis). Other culprits: bone spurs (bony growths caused by arthritis) that press on the nerves or cause spinal stenosis (narrowing of the spinal canal, which also pressures nerves) or spondylolisthesis (weak and slipped joints). And hard or sudden falls can fracture vertebrae made weak and porous by osteoporosis.
Problem: Your back hurts because something’s wrong elsewhere in your body. Doctors call this “referred pain” because it’s not caused by the back itself.
Why it hurts: Endometriosis, kidney stones, or pregnancy weight can trigger back pain that may become chronic. So can fibromyalgia, a disorder of widespread muscle/ligament/joint pain, fatigue, and tenderness at trigger points through the body, most often the lower back.
One reason we get — or can’t get rid of — back pain is that we’re unaware of the things we do (many of them seemingly harmless) that can wreak havoc. The majority of adults unknowingly develop habits that lead them to tighten their neck, shoulders, and back or use the wrong muscles in the wrong way,” says Dr. Hochschuler. “Muscles that were not designed to support your back end up doing just that.” Check out the simple changes below.
STANDING AND MOVING
1. Stand straight with weight evenly distributed between toes and heel.
2. Never reach, bend, and twist at the same time. “Combining these three movements is one of the worst things you can do,” says former dancer Patricia Ladis, cofounder and director of the Kima Center for Physiotherapy and Wellness, in New York City. To move clothes from a washer to a low dryer, take a wide stance, pull clothes to you, then pivot or step to dryer and squat with back flat to put in clothes.
3. Don’t reach too far or too high. Any excessive movement that causes you to tilt your chin upward compresses your spine. Use a stepladder to change a lightbulb or retrieve a can from the shelf, get in the tub to scrub it, and walk around the bed when changing sheets.
4. To pick up or lift an object, get close, take a wide stance and bend at hips and knees, not at your waist.
5. Pack groceries in two small bags, not a single large bag. Carry one in each hand for balance.
6. Place thick, nonskid rubber mats in front of the kitchen sink or next to the ironing board. Standing for long periods on a hard floor can cause muscle fatigue. Or rest one foot on a low stool, tipping pelvis into proper position and relieving pressure on lower back. Switch feet every 5 to 15 minutes.
7. Buy back-friendly sofas and chairs. If you don’t have a firm (not down-filled) chair or sofa, tuck a pillow or rolled-up towel vertically along your spine so it supports your mid and lower back, and sit up straight, with feet flat on the floor or on a footstool.
8. Be sure your mattress supports your spine. Medium-firm (not extra-firm) is usually best. Interim solution for a too-soft mattress: Slip 3/4-inch-thick plywood between mattress and box spring or move the mattress to the floor.
9. Place extra sleep pillows strategically. Back sleepers: Tuck a bolster or pillow under knees, a smaller one under lower back. Side sleepers: Wedge a pillow between knees. Stomach sleepers: Prop a small pillow under waist or shins.
10. Be smart about yard work and snow. Kneel or squat, don’t bend, to weed. Gently pull in abs. Push snow to the side or use a blower. If you must shovel, bend knees, one foot slightly in front of the other. Facing pile, lift the load, slowly pivot and dump it.
11. Back pain can begin with bad footwear. Shoes with firm soles and good arch support will position your pelvis correctly. Save flip-flops for the beach and thin-soled shoes (even ballet flats) for times when you aren’t walking or standing for long periods.
12. Nix heels higher than two inches for all-day wear.
13. Lighten up that purse. Toting more than 10 percent of your body weight is asking for trouble. A backpack is best. Or put heavy items near the bottom and switch bag from side to side throughout the day. A broad shoulder strap is better for heavy loads than carrying a purse in your hands.
14. Sit up straight. “Sitting puts 40 percent more pressure on your spine than standing,” says Dr. Dugan. Imagine a string pulling you up from the top of your head to activate postural muscles on either side of the spine. Be sure that your feet are flat on the floor or resting on a footstool and that your forearms are supported on armrests. (Crossing your legs tilts your pelvis backward, putting increased pressure on your lumbar disks.) Stand, stretch, or walk around every half hour.
15. Keep the center of your computer screen at eye level so you’re not tilting your chin up.
16. Use a telephone headset. Never cradle a cell phone or receiver between your ear and shoulder.
17. Place everything on your desk within arm’s reach. If you’re on the phone and can’t easily reach a file, stand up to get it.
18. Opt for a desktop computer. “Most physical therapists want to throw laptops out the window,” says Ladis. “I tell my patients who use one to work no more than an hour at a time on it and to take frequent breaks.” To make a laptop more back-friendly, install an external keyboard and mouse, and use a laptop desk (available at office-supply stores) so that the machine sits at eye level and your elbows are supported at a 90-degree angle.
19. Prop up books, reports, or papers on your desk so you don’t have to look down to read.
20. Invest in a well-built chair. Your chair should have lumbar support for your lower back, padded armrests, and the ability to adjust the height of the seat to fit yourself to your desk and your computer.
5 Treatment Options
If back pain doesn’t go away, don’t put off doing something about it. Options range from massage and acupuncture to medication, pain-zapping injections, outpatient procedures, and surgery. “Sixty to 75 percent of back-pain patients can be helped by a combination of these techniques, treatments, and drugs,” says Jeffrey Y. Ngeow, MD, a pain specialist at Integrative Care Center at New York’s Hospital for Special Surgery.
1. BODY THERAPIES
Massage. Research supports using massage for simple lower-back pain. Particularly effective: myofascial release, a deep-tissue technique that targets the fascia, a weblike layer of connective tissue between the skin and muscles that literally holds the muscles in place.
Acupuncture. “Studies suggest it stimulates blood circulation as well as pain-relieving endorphins in the brain and spine,” says Dr. Ngeow. You get the best results from twice-weekly treatments for two to three weeks. “If you don’t feel better after six to eight sessions, stop,” says Dr. Ngeow. “You’re wasting your money.”
Spinal manipulation. Osteopathic physicians, physical therapists (PTs), and chiropractors apply controlled pressure to mobilize joints, increase range of motion, improve circulation, and stimulate nerve centers. While manipulation has been widely studied and is considered safe for most people, if you don’t feel better after one month of treatments, stop.
Yoga. The best classes for back pain: Vini (one-on-one therapeutic yoga); Iyengar and basic Hatha (which emphasize position and alignment); or restorative yoga (for breathing and relaxation).
Avoid: Bikram (yoga done in a very hot room) or Ashtanga (“power” yoga). Consider starting with a private session to gain confidence and learn correct postures, and always tell your teacher you have back problems.
Other movement and exercise programs, such as tai chi, Feldenkrais, or the Alexander Technique, also build muscle strength and help you change unconscious physical mistakes that can trigger tension and pain. Pilates, an intense program of core-strengthening exercises, is great for maintaining a strong back — but don’t try it if you’re in acute pain.
Doctors treat persistent back pain with several types of prescription drugs.
Anti-seizure medications such as Neurontin and Lyrica (recently approved by the FDA for fibromyalgia) as well as low doses of older antidepressants (Elavil, Norpramin) and newer siblings (Cymbalta) work by altering the brain’s perception of pain as well as by promoting a good night’s sleep, which is essential for muscle repair and stress reduction.
Prescription muscle relaxants (Soma, Flexeril, Skelaxin) work on either the central nervous system or the muscle itself to reduce spasms and pain.
Anti-inflammatory patch was approved by the FDA last year. Sold by prescription (brand name: Flector), it lessens the gastrointestinal upsets associated with oral anti-inflammatories, such as aspirin, because the medication goes directly into the bloodstream, bypassing the stomach.
3. PAIN INJECTIONS
Shots, optimally administered by an anesthesiologist knowledgeable about backs, provide short-term relief for acute pain and perhaps prevent it from becoming chronic.
Anesthetics such as Bupivacaine or lidocaine coupled with a steroid (usually cortisone) can be injected directly into knotted muscle fibers to break up a spasm; around facet joints (small joints at the back of each vertebra that allow the spine to bend); in the epidural space surrounding the spinal column; or around nerve roots to reduce inflammation (nerve blocks).
Prolotherapy involves injecting ligaments or tendons with compounds such as dextrose (sugar) and lidocaine over a period of several months to kick-start the body’s natural healing process.
Though its effectiveness remains fodder for debate, proponents contend that prolotherapy strengthens these tissues, helping them better support the back.
4. OUTPATIENT PROCEDURES
Pulsed radio-frequency ablation. Using a local anesthetic, a doctor inserts a needle into the inflamed area and stuns the nerve with a radiogenerated electric current, shutting off pain signals. Relief can last months, even years.
Electrical stimulation. This technique sends electric signals deep into muscles via thin electrode patches worn on the skin, creating an electrical field that blocks chronic pain. A portable transcutaneous electrical nerve stimulation machine costs about $45 a month to rent, $395 to own.
Spinal stimulators. Doctors use minimally invasive surgery to implant tiny electrodes along the spine. These can emit a low-level electric current that you turn on and off via remote control to block pain. Most patients say it feels like a pleasant tingling.
5. INPATIENT PROCEDURES
“Americans have back surgery twice as often as people in other countries,” says Dr. An. “We also have the highest rate of failed back surgeries.”
Surgery shouldn’t happen without asking why, how much pain is involved, and what recovery is really like. The most important query: What if I wait? “Very often symptoms improve with no intervention at all,” says James N. Weinstein, DO, chairman of orthopedics at Dartmouth-Hitchcock Medical Center.
Coming Back from a Back Attack
Unless your back pain is an emergency, you can usually ease or eliminate it with these do-it-yourself strategies, says Dr. Dugan.
WHAT TO DO IMMEDIATELY
Rx 1: Lie on your back with a pillow under your knees, or on your side with a pillow tucked between your knees and ice your back to calm inflammation (20 minutes on, 20 minutes off). If ice doesn’t help, try the opposite — a heating pad or warm bath. Heat dilates the blood vessels, bringing more healing oxygen and relaxing muscle spasms, and it also reduces pain. Take acetaminophen or a non-steroidal anti-inflammatory drug (NSAID), such as ibuprofen, naproxen, or aspirin. As soon as possible, try to walk, even if it hurts — staying in bed too long makes muscles and joints stiffen, increasing pain. But don’t lift anything heavy or bend from the waist.
Rx 2: As pain eases, begin gentle stretching and strengthening exercises. Continue, even when your back feels better, to strengthen the muscles that support the spine.
STILL HURT AFTER TWO DAYS?
Rx 3: See your primary-care physician for a back exam. He or she may prescribe stronger painkillers, muscle relaxants, or an x-ray to see if there’s a disk problem or fracture. If pain lasts more than six weeks, you may need a CT scan or an MRI to check for disk issues, spinal stenosis, or other conditions. If pain persists, get referred to a back-pain specialist or integrative medical center, which combines physicians and related services.
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