A Primer on Back Pain

WHY YOUR BACK HURTS
Most low back pain results from mechanical disorders of the spine related to overuse, such as habitually poor posture, or injury or deformity of a portion of the spine, such as herniated disc. The other 10 to 15 percent of cases are medical, caused by systemic illnesses, such as nerve damage from diabetes or fibromyalgia, and require a more complete evaluation. I refer to this form of back pain as medical low back pain.

Discomfort associated with specific causes of low back pain has reproducible characteristics. For instance, ruptured discs pressing on nerves cause pain that runs from the back to the lower leg and foot. The pain from muscle injuries in the back may spread across the low back but not lower than the buttock. Knowing where the pain initially starts and ends helps us make a good guess about the cause.

Mechanical disorders are caused by local problems in the bones, joints, tendons, ligaments, muscles, and nerves of the low back. Characteristically, being active or at rest has an effect on the intensity of the pain, either making it better or worse. The position of the spine also affects the degree of pain. If you have a disc herniation, you feel more pain when you sit, while people with spinal arthritis feel worse when standing. Most mechanical problems heal or improve with time, physical therapy, and medications. Only 1 to 2 percent of these mechanical difficulties call for surgical intervention, such as when they cause loss of bladder control or leg weakness.

Figure 1.1 This side view shows the major organs and blood vessels near the lumbar spine.

Medical disorders cause symptoms throughout the body and are not limited to discomfort in the lumbar spine, and they don't get better or worse with activity or rest. In addition, many organs such as the kidneys, bladder, gastrointestinal system, lymph nodes, and major blood vessels fit up against the lower back (see fig. 1.1). Diseases that affect these organs can cause back pain, with each organ system causing a certain kind of pain. When back pain originates in a structure other than the spine, the unique character of the pain can help doctors find the diseased organ system.

WORKING WITH YOUR DOCTOR
Your doctor needs a complete picture of you and your back pain before he or she can get to the bottom of the problem. During the telling of your story and a physical examination, any one fact may be the clue that solves the puzzle of your back pain. In fact, most diagnoses are established during the history portion of the examination. The rest of the process identifies the correct diagnosis from the variety of possibilities developed by your description of your back pain.

Your age and gender, naturally, are important to a correct diagnosis. For example, more herniated discs occur between the ages of 25 and 45. Conversely, approximately 80 percent of people with cancer of the spine are fifty or older. Men have back pain more frequently than women, some of which may be explained by occupational exposure to more physically strenuous work. Certain disorders occur exclusively or predominantly in women, such as back pain during pregnancy and osteoporosis. (Men are at risk for this thinning of the bones, too, but the risk is greater for postmenopausal women.)

The history you provide is the most important part of the diagnostic process. The more complete the information, the greater its value. Every subsequent step is used to confirm the ideas and even hunches developed during the medical history. The first part of your history, the chief complaint, is your description of what brought you to the doctor. In most circumstances, the chief complaint is "I have a pain in my back." Another frequent chief complaint is "I have a pain in my back that runs down my leg to my foot." Your description guides the doctor's questions.

Telling your story allows you to describe those events that you believe are most important in explaining the evolution of your back pain. Your doctor may or may not ask questions as you progress with your narrative. A physician may interrupt to ask a question if a particular point is essential to differentiate between diagnostic possibilities. For example, you may be asked: "Did the pain that ran down your leg go to your big toe or small toe?"

Help yourself and your doctor by gathering your thoughts about your back pain and organizing the description of your symptoms and questions you want to ask. Perhaps you can store the information in your head, but writing it down may be more useful. By carefully thinking about your back pain, you will have organized information necessary to start the diagnostic process. Also, bring a list of your medicines—or the actual medicines—with you and the names and addresses of your other healthcare providers.

WHAT DIAGNOSTICS CAN AND CANNOT TELL YOU
Diagnostic "pictures" have importance only in the context of your current clinical complaints. Any number of abnormalities may appear on the X-rays or MRI, but these results may be of little consequence in explaining and treating the problem that prompted a visit to a new doctor.

I repeat this scenario with patients again and again, and it serves to shed light on both the advantages and disadvantages of rapid advancements in medical technology. We now have the ability to look inside the human body and obtain highly detailed images without exposing people to radiation. The MRI scanner uses large magnets and radio waves and presents visual images of the structures in the spine that were difficult to see with older, radiation-based technology. The computed axial tomography scan (CT) uses X-rays (radiation) to identify structures in and around the spine. We can put multiple CT pictures together to achieve a three-dimensional view of the spine.

TREATMENTS
Pain from a mechanical disorder, such as muscle strain, joint irritation, or a herniated disc can improve if you control physical activities, use over-the-counter medications, stay fit with aerobic exercise and most importantly, self educate. If, however, you are not progressing much, or have a bad reaction to your medicine, such as stomach upset or other side effects, contact your doctor to share that information. He or she may be able to change your medicine or dosage to reduce or eliminate the side effects.

Control physical activities but limit bed rest
In the past we were told to lie down if we had back pain, to let the muscles rest and heal. This is wrong! Now we know that bed rest is no better to resolve back pain than being up and walking around. Movement seems to help the tissues of the back heal more rapidly, too. Extended bed rest, on the other hand, reconditions the heart, lungs, stomach, and skeletal muscles. So keep bed rest to a minimum. Studies have shown that two days of bed rest is as good as seven days of bed rest for the relief of back pain. The benefits of bed rest are also limited if pain travels to your leg. In a study of 183 people with sciatica from a herniated disc, people given bed rest for two weeks did no better than those allowed to walk around.

On the other hand, being out of bed does not mean returning to your usual daily work and recreational activities. Stay home from work until you are able to walk or stand for 30 minutes without pain, and you feel comfortable sitting for 20 to 30 minutes without increased pain. If you have acute low back pain, limit your activities and you will have a faster recovery and be much less likely to have chronic or recurrent episodes of low back pain. Increase activity as pain decreases.

Bed Rest Positions
When bed rest is indicated, a couple of positions are most comfortable. The semi-Fowler position places the least pressure on spinal discs, joints, and muscles: Put a small pillow behind your head and two to three pillows under your knees to flex your hips and knees. Your mattress should be firm, but it may feel better to lie on a comforter on the floor.

Get Out of Bed Carefully
Another comfortable position is on your side with a flat back, with your legs curled up with a pillow between your knees. This is a side semi-Fowler position and is the way to get into and out of bed. Push against the bed with your lower arm while letting your legs slide off the edge of the bed. The weight of your legs will swing your chest up with the help of your lower arm. To get back into bed, do the reverse. Shift your upper body weight to the palm of your hand resting on the bed. Slowly let your body down, shifting your weight to your forearm, elbow, and shoulder while you swing your legs up to the bed. Keep your back straight.

Don’t Sleep on Your Stomach
This position is particularly stressing on the lumbar spine because it increases the curve and tends to stretch the muscles in the pelvis, causing more pain. If you have to sleep on your stomach, put a pillow or two under your abdomen. This will flatten your spine and place less pressure on the psoas muscle in the pelvis.

Prevention
Once you have had one back attack, you are at greater risk of having another within a year. Some studies suggest this is true for as many as 50 percent of back pain sufferers. However, the second attack is usually milder than the first. The second attack occurs because people forget the lessons learned from the first back pain episode. They go back to their old habits and lift objects from awkward positions, stretch too far, or sit too long.

Do not become a repeat back offender. Remember what caused your first back attack. Practice good body mechanics, rest when appropriate, and exercise at the correct time of the day (generally later in the day). If you follow these simple rules, a second attack of pain is less likely.

PARTICIPATING IN SPORTS
In the acute stage of back pain, limiting sports activities is appropriate. Movement is important, but shooting 18 holes is not going to be helpful. Allowing your back to heal will actually allow you to return and stay functional as opposed to going back too soon and having recurrent attacks stretching out your recovery. Sport activities can be divided into low, moderate, and high risk for developing low back pain. If you have back pain and are trying to start a new sport, you should speak with your physician before starting a new activity. In general, some of the low-risk sports are compatible with low back pain. These sports are bicycling and swimming. Racquet sports are difficult to start if you are having acute back pain. Also, I have assumed that amateur sports persons are involved with these activities. Professional athletes have greater risks.

• Low-risk sports: bicycling, hockey, skiing, soccer, squash, swimming, tennis
• Moderate-risk sports: baseball, basketball, bowling, some types of dancing, golf, horseback riding, jogging, rowing
• High-risk sports: diving, football, gymnastics, weight lifting

The low-risk sports in general put little pressure on the spine. In addition, the risk of continuous twisting is small. The moderate-risk sports are associated with jumping (basketball, dancing, horseback riding, jogging) or twisting (baseball, bowling, golf, rowing). Jumping places increased pressures on discs. Discs are at risk of herniation or more rapid degeneration. Twisting places pressure on the facet joints. Continuous twisting causes increased joint pain that continues after the sports activity is completed. High-risk sports are associated with high velocity impact (diving, football) or hyperextension (gymnastics) or excessive weight (lifting).

General recommendations for all sports are to use good technique from the outset. You should learn from a good teacher if you have not had experience with the sport. You should ask a ski instructor about appropriate technique to protect your back. You should use appropriate equipment to decrease your exposure to risk. For example, good running shoes with appropriate cushioning are important. Running on soft surfaces like grass or asphalt is better than running on concrete.

BACK PAIN DURING PREGNANCY
Half of all pregnant women develop moderate to severe back pain.

This pain can be from hormonal changes that alter the flexibility of ligaments and joints in the pelvis, or simply the mechanical problem of the added weight in the pelvis. The pressure on the supporting structures in the pelvis or a marked increase in the lumbar curve (lordosis), strains the supporting muscles. In the nonpregnant state there is practically no motion in the joints of the pelvis, the front of the pelvis and sacroiliac joints. However, during pregnancy, a hormone, relaxin, is produced and it allows increased motion of the pelvic joints, and this causes tension in the relaxed capsule and ligaments. Increased lordosis also increases the weakness of the abdominal muscles and puts greater strain on the muscles near the spine. Active movement such as climbing stairs increases the strain.

Being physically fit before pregnancy may cut your risk of developing back pain. If a pregnancy is in your future, a physical fitness program with aerobic and strengthening exercises is helpful. If you are already pregnant and have back pain, exercises and external supports can be helpful to you.

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