Back Pain

Among conditions that are both painful and non-life-threatening, back pain is one of the most common, affecting four in five Americans at some point in their lives. But the good news is that back pain need not govern how you live your life.

Thanks to the pioneering work of back pain researchers, treatment has undergone a sea change. We now appreciate the central role of exercise in treating back problems and maintaining a healthy back. We also know that the best strategy for preventing back pain recurrence is to reduce your risk factors—for example, by losing excess weight and becoming more physically active. This is good news both for people suffering with back pain and for society at large, because the overall costs of this common condition are staggering, with some estimates of economic impact running from $84.1 billion to $624.8 billion in the United States alone.

What puts you at risk for back pain?

Although anyone can develop a backache, regardless of health or circumstances, research has found that some conditions or activities put you at greater risk for such problems. These conditions or activities are known as risk factors. Some are things you can change. Others aren’t. But knowing the risk factors will at least enable you to deal with those that are manageable.

Risk factors you can’t change

No matter what you do, some risk factors for back pain are beyond your control.

Age. Although back pain can affect people at any age, episodes are most frequent in midlife, when changes occur in the bones and joints of your back, even in the absence of any injury. Discs (the structures that serve as cushions between the bones in the spine) tend to wear out and sometimes lose their structural integrity. These changes can cause pain.

Osteoporosis (loss of bone density and strength) can be another problem, causing severe weakening of vertebrae that may eventually lead to vertebral fractures. Vertebral fractures can cause a loss of height and a rounding of the back. They can also be very painful.

While back pain problems are more common in people in their middle years, in older individuals back pain attacks are more severe and last longer.

Gender. Studies suggest that back pain plagues men and women equally. However, the types of back pain they have may differ.

In Western industrialized societies, men are more apt to suffer from disc problems, and they are more likely to be treated surgically. These differences probably reflect the fact that a greater number of men than women work in jobs that involve heavy lifting, pushing, and pulling—and the fact that men in such jobs often feel the need to return to work as soon as possible.

On the other hand, women often have backaches during pregnancy, particularly during the final trimester. And although the discomfort usually recedes and disappears after childbirth, it can become chronic. The exact reason for this kind of back pain isn’t known, but several factors probably contribute: ligaments normally loosen during the third trimester, abdominal muscles stretch and weaken, and carrying the developing baby and giving birth stress the back. Following childbirth, the task of caring for—and carrying—an infant or small child further taxes the lower back.

A number of other back conditions are also more common in women. Because older women suffer from osteoporosis at higher rates than men, they are more likely to have vertebral fractures. Women are also especially susceptible to degenerative arthritis of the lower spine, a condition that generally involves the vertebral joints, and they are more likely to develop spondylolisthesis (an abnormal forward displacement of a vertebra relative to the one below it).

Family history. Heredity appears to play a role in certain types of back pain. Defects of the discs seem more common in some families; a hereditary difference in the chemical makeup of discs may render them more prone to fragmentation or herniation, conditions that can trigger back pain. Two other back conditions that tend to run in families are ankylosing spondylitis (see “Arthritis”) and spondylolisthesis.

Risk factors you can change

You can’t change your genes, gender, or age, but you can change your lifestyle in ways that may lessen back pain or help you to cope with it better.

Work and play. Certain jobs and activities put a greater strain on your back. Riding in motor vehicles is notoriously hard on your back, for instance, because it involves prolonged periods of sitting and exposure to vibration. The sitting positions necessary for office work—from typing to computer programming—can also eventually take a toll on your back regardless of your age.

Several other job-related activities increase the likelihood of future back problems:

• lifting or forceful movements such as pulling and pushing
• frequent bending or twisting of the back
• heavy physical exertion
• maintaining the same position for long periods
• repetitive motion patterns
• prolonged exposure to vibration.

Smoking. Smokers are also at greater risk, possibly because smoking damages blood vessels that bring nutrients to the spine. Smokers are much more likely than nonsmokers to develop chronic, disabling back pain.

Hardly a day goes by without a headline in the health media about the results of a new study. Often the news is that what we thought was healthy (or unhealthy) actually isn’t. Then, a year later, another headline comes along to say just the opposite. Who’s right?

The results of studies do differ. Sometimes it’s because of the way a study was designed. For example, if you’re testing a new drug, you’re likely to see more improvement if you test it on people with severe cases of a disease rather than those with mild or moderate cases. The sicker people have more to gain, and any small improvement in the drug’s effectiveness over the usual treatment tends to stand out. Other times a study is just not very well designed or carried out, although this does not always stop the health press from seizing on a controversial finding and hyping it.

This Special Health Report attempts to reduce the confusion and mixed messages by relying whenever possible on two special kinds of scientific tools: meta-analyses and systematic reviews. These are “studies of studies” that pool findings from multiple previous pieces of research. The result is a kind of progress report on what scientists think they know about a health issue.

The prestigious Cochrane Collaboration is known for its systematic reviews, and its work is cited often in this report. It’s a global network of health practitioners, researchers, patient advocates, and others who help to conduct comprehensive reviews of the scientific literature on a topic, both published and unpublished.

A meta-analysis gathers a smaller selection of studies than in a systematic review and attempts to pool their findings into a result that is stronger than that of any individual one.

These tools help doctors and their patients make better decisions. They answer the question, “Based on the best studies conducted to date, does this particular treatment work—or does it work better than other existing treatments?” An individual study may say “yes” or “no,” but systematic reviews and meta-analyses can sometimes prove the old saying that there’s strength in numbers.

Physical characteristics and posture. The good news is that your build, weight, and height seem to have little to do with your likelihood of developing back pain in the first place. Even a moderate difference in leg length—up to three-quarters of an inch—doesn’t appear to make a difference. And despite your mother’s admonition to “sit up straight,” experts now agree that, in most cases, posture alone, whether bad or good, will neither predispose you to back pain nor shield you from it. Slumping and slouching don’t seem to have much effect on the basic health of your spine.

But before you slump back in your chair, note that poor posture can worsen existing pain. Improving your body mechanics can help relieve your symptoms and prevent recurrences (see “Building muscles” and “Stretching”). Being physically out of condition is an important reason people have recurring bouts of the “sprain and strain” type of back pain.

And note that being overweight puts you at increased risk of having your symptoms return. What’s the connection? Doctors aren’t sure. Although it seems logical to think that carrying extra body weight causes back pain by increasing the strain on the spine, the connection may be more complicated than that. For example, becoming overweight tends to make you less physically active, and that could make back pain more likely.

Psychological factors. A growing body of evidence shows that emotions and psychological well-being have a significant influence on physical health. It is not surprising, therefore, to learn that these factors also affect the risk of having back problems. Psychological factors such as stress, anxiety, and negative mood and emotions all increase the likelihood of developing back pain. Such factors seem to be especially important in determining whether an acute bout of back pain will become a chronic problem.

One review of studies that examined this question, for example, found that people who were distressed or depressed were more likely to develop chronic back pain than other people. People who are unhappy at work because a job is unfulfilling or the pay is low also tend to develop more back problems than the general population. The reasons for this are not completely understood. Part of the answer may lie in the fact that chronic pain and depression share some of the same biochemical roots. The neurotransmitters serotonin and norepinephrine, for example, not only are involved in mood disorders such as depression but also are important in producing the sensation of pain. Anxiety and depression may sensitize a person to pain, making him or her feel worse. Sleep deprivation can also intensify the subjective perception of pain.

Causes of back pain

Does this sound familiar? One day, you wake up and there is just something funny in your lower back—a twinge, a tightness, a warm ache. You gently try to stretch it out, but it’s no use: by the end of the day you are hunched over in pain. You’ve pulled your back out again.

Why does your back hurt on this day but not another day? Although many episodes of back pain can be associated with a specific event—a fall, a sudden off-balance movement, or overdoing it in the garden or at work—doctors can’t always find an exact anatomical explanation.

Even so, it is usually possible to categorize the type of back problem you have. The type of pain and the location of the pain are often enough for an experienced doctor to accurately diagnose a particular back condition and suggest appropriate treatments (see “Diagnosing back pain”). When the treatment is appropriate for the problem, then recovery should go smoothly. With a mismatch, recovery may falter (see “Creating a treatment strategy”). Following is some basic information on the major causes of back pain.

Sprains and strains

Sprains and strains are the most frequent causes of backaches. Sprains affect ligaments, the tough, fibrous bands of tissue found where bones, such as the vertebrae in your spine, connect at joints. Strains are injuries of your muscles or your tendons, which connect muscles to bones.

Nerve-compression syndromes

The next most common cause of back pain is a compressed or “pinched” nerve. Two common types of nerve-compression syndromes are disc problems (such as a herniated disc) and spinal stenosis, which occurs when a narrowing of the spinal column puts pressure on nerves in the spine.

Spinal stenosis

Spinal stenosis is a narrowing of the spinal canal, the channel in the vertebrae that the spinal cord passes through. As the space becomes more constricted, pressure is applied to the nerves, causing pain and certain other characteristic symptoms. Spinal stenosis is more common in people over age 50, since age-related degenerative changes are often the source of the problem. However, some people who naturally have smaller spinal canals are more likely to develop the condition and to be diagnosed earlier in life.

Arthritis

Degenerative arthritis of the facet joints is common among older people. It often causes varying degrees of back pain, usually intermittent, over months or years. The most common of these arthritic ailments is ankylosing spondylitis (from the Greek ankylos for “bent,” and spondylos for “vertebra”). In this painful and disabling condition, the spine becomes inflamed and stiff. The disorder usually develops before age 40 and can be mistaken for a back strain or a disc problem when mild. Sometimes, people with this condition have pain in both sides of their lower back or pelvis. When severe, it can cause increasing pain over time, eventually resulting in fusion of the spinal joints and a completely rigid back.

Acute or chronic?

The natural history of a back problem—and thus the likelihood that it will improve on its own—depends to a large extent on whether it’s acute or chronic.

Acute back pain strikes swiftly. It may follow something you did at work or at play. It can also be caused by a compressed nerve or a degenerative condition such as arthritis. Studies suggest that one-third of people with acute back pain from sprain or strain will be much improved in as little as one week after the start of their symptoms, and two-thirds will experience improvement within seven weeks. More often, however, painful backs mend more slowly, over four to eight weeks.

Unfortunately, the problem often recurs: about 40% of people who develop low back pain will experience another bout of symptoms within six months. Therefore, after the initial acute attack retreats, prevention is key.

Chronic back pain by definition shows little or no improvement after three months. Often the precise cause of the pain is difficult to pinpoint, and it gets progressively worse. In general, chronic back pain responds best to a management program that includes several different approaches—for example, a combination of pain-relieving medication, physical activity, and a complementary therapy such as acupuncture. You may need to visit a pain clinic in order to manage the pain. Work with your doctor to find the best combination for you. Your goal is to control pain and remain as functional as possible, so you can continue to live the life you want.

What can you do?

It’s helpful to be an active participant in your care. Learn everything you can about your condition. Then help your doctor decide on a course of action that’s best suited to you. Ideally, this “patient-centered care” means your expectations and preferences—not your doctor’s—should guide your treatment plan.

Cold and heat

Applying moderate cold or heat to your back can reduce your discomfort. It’s best to use cold compresses or an ice pack, not heat, immediately following an injury. This can alleviate pain by numbing the area and can prevent or reduce swelling caused by inflammation. About 48 hours after the onset of back pain, though, applying heat to your back may be more helpful. The warmth soothes and relaxes aching muscles. Heat also increases blood flow, which carries oxygen and nutrients to the injured area and thus promotes the healing process. Generally, electric heating pads and hot-water bottles are effective and easy to use. Heat therapy tends to help only in the early days of an acute attack (up to a week). Make sure not to apply heat or cold directly to exposed skin, and don’t fall asleep; skin burns or irritation may result.

Rest—but not too much

Extended bed rest was once a mainstay of treatment for low back pain, but no longer. Although lying in bed does minimize stress on the lumbar spine, extended bed rest creates other problems:

• Muscles lose conditioning and tone.
• Gastrointestinal problems, such as constipation, may arise.
• Blood clots may develop in the veins of the pelvis and legs, which raises the risk of pulmonary embolism (a   serious medical condition where a blood clot, usually dislodged from a vein in the pelvis or leg, blocks an artery in the lung).
• Depression and an increased sense of physical weakness and malaise may occur—a common phenomenon in people confined to bed rest.

For all these reasons, it’s far better to engage in a limited amount of physical activity than to lie in bed. So get up regularly and walk around a bit, to the extent you can. Research shows that an early return to work—with some restrictions or light duty, if necessary—is preferable to staying home from work for an extended period.

That said, some bed rest can also be useful, particularly if you are in severe pain while sitting and standing. Try to restrict bed rest during the day to a few hours at a time, for no more than a couple of days. To ease the strain on your back, try putting pillows under your head and between your knees when lying on your side, under your knees when lying on your back, or under your hips when lying on your stomach. These positions reduce pressure on your back from sitting or standing—especially on the discs, ligaments, and muscles. Alternatively, you may be more comfortable sitting upright rather than lying down. Many people wonder whether a particular type of mattress makes a difference, but there isn’t much proof of this (see “Ask the doctor: What type of mattress is best for people with low back pain?”)

Get moving

The sooner you can get up and moving, the faster you will recover. Exercise therapy can help the recovery process during an acute episode of back pain, prevent repeat backaches, and improve your day-to-day function even if you have continuing, chronic back pain.

Developing a suitable exercise program under expert supervision will enable you to build strong, flexible muscles that will be less prone to injury. If you have acute back pain, the goal is to help you resume normal activities as soon as possible and to remain symptom-free following recovery from the immediate attack. If you have chronic back pain, work with your physician to define your desired functional goal—whether it involves being able to tour museums, play with your grandchildren, or simply sit in the backyard reading a good book.

Any exercise program should be customized to meet your individual needs and introduced gradually a couple of weeks after the onset of symptoms or when you are feeling reasonably comfortable. One golden rule about any exercise program is to stop if it becomes painful. Exercise is meant to help, not hurt.

Another guiding principle of exercise for back pain is “start low and go slow.” Begin with a low level of exercise that you can do without pain or strain and ramp up gradually. Walking is a good starter activity. Start with a duration you can easily tolerate, and then add 10% to 15% to your time every week. Most people can double their walking time within five to six weeks.

If you were exercising before an episode of back pain and then had to slow down or stop for a while because of the pain, don’t resume exercising at the same level as before the episode. If you try to pick up your exercise routine where you left off, you might get hurt. Start by doing less (fewer minutes or repetitions) and gradually build back up to where you were before.

Building muscles

Aging and lack of exercise can leave you with weak, deconditioned back and abdominal muscles, causing or worsening back pain. That’s why stretching and strengthening these muscles—the “core” muscles of your torso—is so important to recovering from back pain and preventing a recurrence of the problem.

Exercise strengthens and stretches the muscles that support the spine. A stretching and strengthening regimen should target the back, abdominal, and buttock muscles (see “Back- strengthening exercises”). Strong abdominal or flexor muscles, for example, help people maintain an upright posture, as do strong extensor muscles, which run the full length of the back and maintain alignment of the vertebrae. Meanwhile, the two iliopsoas muscles (which run from the lumbar vertebrae to the hips on each side) and the buttock muscles help support the back during walking, standing, and sitting. In addition, the muscles of the upper legs should be flexible and strong, because they’re connected to the iliopsoas and buttock muscles and, if weak and tight, can strain the supporting structures of the back.

Stretching

Stretching is a valuable component of any treatment plan for a person plagued by back problems. Most experts believe that supple, well-stretched muscles are less prone to injury. Indeed, shorter, less flexible muscle and connective tissues restrict joint mobility, which increases the likelihood of sprains and strains.

Stretch regularly but gently, without bouncing, as that can cause tissue injury. Beginners should start by holding the stretch for a short time and gradually build up to roughly 30-second stretches.

The value of healthy living

A recurring back problem may be a message telling you to examine aspects of your lifestyle that might be contributing to the problem. Maintaining a healthy weight and not smoking lead the list of lifestyle factors that can help your back.

Maintain a healthy weight

Although carrying too much weight is not proven to cause back pain conditions, being overweight or obese can slow your recovery. Those extra pounds also increase the risk that back pain will return.

The heavier you are, the greater the load your spine must carry. To make matters worse, if the bulk of your weight comes in the form of abdominal fat, rather than muscle, your center of gravity can shift forward—a condition that puts added pressure on your back. By maintaining a healthy weight, you can ease the burden on your spine.

Kick the habit

You’ve undoubtedly heard this message before: smoking harms your health. Not only does it raise your risks for lung cancer, heart disease, hypertension, and other serious health problems, but it also jeopardizes your back.

Research shows that smokers have more frequent episodes of back pain than nonsmokers, and the more people smoke, the higher the risk of such episodes, according to one study. Nicotine is toxic to the intervertebral discs, contributing to low back pain in two ways. First, nicotine hampers the flow of blood to the vertebrae and discs. This impairs their function and may trigger a bout of back pain. Second, smokers tend to lose bone faster than nonsmokers, putting them at greater risk for osteoporosis, another common cause of back pain (see “Osteoporotic fractures”).

Lighten your load

Backpacks have become ubiquitous—at school, at work, at play. But an overstuffed backpack can be a cause of back trouble.

Most orthopedic doctors have long recognized that backpacks increase the risk of certain types of back pain, especially in students. A survey by the American Academy of Orthopaedic Surgeons found that nearly 60% of the doctors responding had treated students complaining of back and shoulder pain caused by heavy backpacks. Hauling an overloaded backpack can also cause muscle fatigue and strain and encourage the wearer to bend forward unnaturally.

If you (or a child or grandchild) use a backpack, use both the pack’s straps instead of slinging one strap over a shoulder. Try to carry only the essentials, and lighten your load whenever possible. Opt for backpacks that have different-sized compartments to help distribute weight evenly. And look for wide, padded straps and a padded back. A strap that fastens around the hips can also redistribute pressure away from the spine and place it on the hips instead. When carrying a heavy load, put the heaviest items as close as possible to the center of the back, and use the hip strap for support. For very heavy loads, use a backpack with wheels. Above all, remember to bend from your knees when picking up your pack.

Follow these basic steps whenever you need to lift something:

• Face the object and position yourself close to it.
• Bend at your knees, not your waist, and squat down as far as you comfortably can.
• Tighten your stomach and keep your buttocks tucked in.
• Lift with your legs, not your back muscles.
• Don’t try to lift the object too high. Don’t raise a heavy load any higher than your waist; keep a light load below shoulder level.
• Keep the object close to you as you lift it.
• If you need to turn to set something down, don’t twist your upper body. Instead, turn your entire body, moving your shoulders, hips, and feet at the same time.
• Ask for help with lifting anything that’s too heavy.

Develop back-healthy habits

Everyday activities, from vacuuming your house to sitting in front of the computer for hours, can take a toll on your back, particularly if you aren’t schooled in proper body mechanics. You can take some of the pressure off your back by following these simple tips:

• While standing to perform ordinary tasks like chopping vegetables or folding laundry, keep one foot on a small step stool.
• Don’t remain sitting or standing in the same position for too long. Stretch, shift your position, or take a short walk when you can.
• When sitting, keep your knees a bit higher than your hips and bend them at a 90-degree angle. Sit with your feet comfortably on the floor. If your feet don’t reach the floor, put a book or a small stool under them.
• Because vacuuming can take a toll on your back, tackle rooms in chunks, spending no more than five to 10 minutes at a time doing this task.
• Choose an office chair that offers good back support (preferably with an adjustable backrest, lumbar support, armrests, and wheels) and set up your work space so you don’t have to do a lot of twisting.
• Try not to overload briefcases or backpacks (see “Lighten your load”).
• Make frequent stops when driving long distances.
• While driving, sit back in your seat, and if your seat does not provide sufficient lumbar support, place a rolled blanket or some towels behind your lower back. Try to shift your weight occasionally. If you have cruise control, use it when you can. Also consider using a foam seat cushion to absorb some of the vibration.
• Sleep on your side if you can, and bend your knees toward your chest a bit. Also, choose a pillow that keeps your head level with your spine; your pillow shouldn’t prop your head up too high or let it droop. Choose a mattress that’s firm enough to support your spine (so that it doesn’t sag into the bed) and that follows your body’s contours.

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