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Back Pain
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.
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.
Back pain can be a
symptom of arthritis or many other conditions. This
material is written for anyone who has back pain, regardless of the
cause.
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), sub-acute 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. Sub-acute 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 sub-acute. 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.
What is the structure of the back?
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 .
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 earing 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. Tendons
fasten muscles to bones. And ligaments stretch from one bone to another to hold
bones together.
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 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 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 yelogram, computerized axial tomography (CAT) scan, or magnetic
resonance imaging (MRI) is needed to confirm the diagnosis and determine if
surgery is necessary.
Spinal
Steosis
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.
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 them-selves. 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 origi-nates 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 material 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 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.
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 an orthopaedist, rheumatologist, 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:
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
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.
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 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.
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.
Acute Low Back Problems in
Adults
The human spine (or backbone) is made up of mall bones called
vertebrae. The vertebrae are stacked on top of each other to form a column.
Between each vertebra is a cushion known as a disc. Ligaments hold the vertebrae
together, and muscles are attached to the vertebrae by bands of tissue called
tendons.
Openings in each vertebra line up to form a long hollow canal. The
spinal cord runs through this canal from the base of the brain.
Nerves from the spinal cord branch out and leave the spine through
the spaces between the vertebrae. The lower part of the back holds most of the
body's weight. Even a minor problem with the bones, muscles, ligaments, or
tendons in this area can cause pain when a person stands, bends, or moves
around. Less often, a problem with a disc can pinch or irritate a nerve from the
spinal cord, causing pain that runs down the leg, below the knee, called
sciatica.
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