BACK PAIN

Introduction

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.

Is There Only One Kind of 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 may be 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.

What Is the Structure of the Back?

Your back is held upright by muscles attached to the backbone. Doctors 
often refer to the back- bone as the spine, spinal column or vertebral 
column. The backbone isn't one long bone, but actually 24 separate bones 
called vertebrae (VER- ta-bray). 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 enable the spine to move and turn in different directions.

What keeps joints and bones from rubbing against each other and wearing
out? Look at the following diagram of the backbone and find the discs
located between each vertebra. These discs are made of cartilage
(CAR-tuh-lij), which is a soft, elastic material. Discs act as cushions,
or shock absorbers. Their main job is to protect the joints from wearing
out. Most joints contain a slippery substance called synovial 
(sin-OH-vee-all) 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.

What Causes Back Pain?

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 included in the following sections.

Ruptured Intervertebral Disc

This may be the most painful, yet easiest condition to identify A 
ruptured or herniated (HER-nee-ay-tid) disc is one that bulges into the 
spinal canal, pressing on the nerve roots. 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 (SY-at-ick) pain. This is severe pain spreading down 
one leg and often into the foot. Sometimes it is the only symptom of a 
ruptured disc.

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. 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

This 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.

Other Rheumatic Problems

Osteoarthritis and ankylosing spondylitis are only two of the more than 
100 kinds of rheumatic diseases. Other rheumatic diseases, such as those 
in the following list, also can cause back pain.

Osteoporosis

This 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

This form of 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)

This rheumatic disorder 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

This 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; or •rarely, a tumor on the spinal 
cord. 

Factors That Can make Back Pain Worse

Stress, poor posture, lack of exercise and being overweight all can 
contribute to the problem. In terms of stress, people react to it 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.

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? If so, look in the stress 
management section of this booklet for some helpful tips.

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 100 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.

How Is a Diagnosis Made?

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 a rheumatologist (a 
doctor who specializes in arthritis), orthopedist, neurosurgeon, 
neurologist, physiatrist or other medical specialist for diagnosis. 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. 

Regardless of what type of doctor you see, there are some things you can 
expect your doctor to do during your visit.

Medical History

Your doctor first will ask you a number of questions, the most common of 
which are listed as follows:

MOST COMMON QUESTIONS DOCTORS ASK ABOUT BACK PAIN

1. What are your symptoms - that is, what aches or pains do you have? 
2. Exactly where is the pain? 
3. Where is the pain the most severe? 
4. When did the pain begin? How long have you had it?
5. Did something specific cause your back pain, such as an accident or 
injury? 
6. What home treatments have you used? 
7. Were you under any additional stress when the pain began? 
8. Do you have any other health problems? 
9. What kind of work do you do? 
10. 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.

Physical Exam

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.

Special Tests

If the doctor needs more specific information, he or she may ask you to
undergo one or more of the following 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; or 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 clearer pictures of soft tissues such
as muscles, cartilage, ligaments, tendons and blood vessels, in addition
to bone structure.

Melogram

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 clearly 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 be ordered:
erythrocyte sedimentation rate (sed rate); •hematocrit and hemoglobin;
white blood cell count; HLA B-27 test; or •chemical profile (SMAC).

Your doctor may order other blood tests. Ask for an explanation of the
tests.

Treatment for Back Pain

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.

Proper Exercise

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 on the following page 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.

(Patients diagnosed by their physidan as having a ruptured disc or
spondylolisthesis should not do the Angry Cat or Hip Kicker exercises.)

Bridging

Lie on your back with knees bent and feet flat on the floor Tighten your
buttocks and roll your pelvis up so as to flatten your upper back
against the floor Hold for five seconds. Relax and repeat.

Double Knee Pull
Lie on your back with both knees bent, feet flat. Bring one knee up,
then the other pulling both to your chest until you feel a stretching in
your buttocks. Bring your forehead to your knees and hold for five
seconds. Put one foot down, then the other Rest and repeat.

Back Erector
Stand up straight. Bring your chest out, shoulders back (military
style). Hold for five seconds. Relax and repeat.

Half sit-up
Lie with knees bent, arms at your side. Reach for knees, raising head
and shoulders off the floor, and continue to breathe. Relax to initial
position.

Hip Kicker
Kneel on hands and knees. While maintaining a straight back, slowly raise
one leg out behind you. Hold for five seconds, then return the leg to the
floor Repeat on opposite side. As you get stronger you may add a small cuff
weight to the ankle.

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.

Heat and Cold

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); or •a commercially made cold
pack.

Be sure not to leave ice on after the skin becomes numb. This could lead
to localized frost-bite. Do not use cold if you are especially sensitive
to it or have decreased circulation or sensation.

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 such as those listed on the following pages.
Sit in a firm
chair with armrest
to relieve pressure
in your back and
shoulders.

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 male it worse. •Use
a firm mattress.

WHEN LIFTING AND CARRYING OBJECTS:
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. Get help with
any object that is too heavy.

CORRECT

When bending down to lift an object, bend and straighten with
your knees instead of your back.

INCORRECT

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.

Weight Loss

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.

Stress Management and Relaxation Exercises

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.

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.

Since we cannot remove everyday events from our lives, the key to
controlling 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.

Medication

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 (an-all-GEE-sics)
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 in the following chart.

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.

Spinal Manipulation

One technique that may bring some short-term relief from back pain is
spinal manipulation. Physical therapists, osteopaths, doctors who are
trained in manipulation and chiropractors apply this technique either
directly by pressing on the spine with their hands, or indirectly by
twisting the shoulder or hip in an effort to force the vertebrae just
beyond their normal range of motion.

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 or neurosurgeon 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 with Chronic Back Pain

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.

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.