Low Back Pain FAQs 9781550093193

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Geisinger Clinic is a multispecialty physician group practice with nearly 650 physicians located in central and northeastern Pennsylvania. The clinic’s mission is “to enhance the quality of life through an integrated health service organization based on a balanced program of patient care, education, research, and community service.” This mission is summarized: “Heal. Teach. Discover. Serve.” To learn more about the Geisinger Healthcare System visit www.geisinger.org

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FAQs* SERIES Also in this series Current Titles Menopause FAQs Rheumatoid Arthritis FAQs Weight Management: Childhood and Adolescence FAQs Weight Management: Adults FAQs Depression FAQs Upcoming Titles Asthma FAQs Hypertension FAQs Headache FAQs Insomnia FAQs Diabetes FAQs

*Frequently Asked Questions

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Author David R. Gutknecht, MD

Series Editor Sandra A. Buckley

2007 BC Decker Inc Hamilton

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BC Decker Inc P.O. Box 620, L.C.D. 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com © 2007 Geisinger Clinic and BC Decker Inc Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher. 07 08 09/PI/9 8 7 6 5 4 3 2 1 ISBN 1-55009-319-3 Printed in Canada Sales and Distribution United States BC Decker Inc P.O. Box 785 Lewiston, NY 14092-0785 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com Canada BC Decker Inc 50 King St. E. P.O. Box 620, LCD 1 Hamilton, Ontario L8N 3K7 Tel: 905-522-7017; 800-568-7281 Fax: 905-522-7839; 888-311-4987 E-mail: [email protected] www.bcdecker.com Foreign Rights John Scott & Company International Publishers’ Agency P.O. Box 878 Kimberton, PA 19442 Tel: 610-827-1640 Fax: 610-827-1671 E-mail: [email protected] Japan Igaku-Shoin Ltd. Foreign Publications Department 3-24-17 Hongo Bunkyo-ku, Tokyo, Japan 113-8719 Tel: 3 3817 5680 Fax: 3 3815 6776 E-mail: [email protected]

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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Introduction “My back is killing me!” “Could I have something dangerous?” “Do I need a magnetic resonance image (MRI) scan or an operation?” “Will I need to miss work or change my job?” These are some of the questions asked by people who seek treatment for back pain, a condition that affects most people at one time or another in their life. If you have a troublesome back, or know someone who does, you will want to know as much as you can about the problem, about the best ways to treat it, and how to possibly prevent it. There are many causes of back pain. Only a few are truly dangerous. There are also many ways to evaluate and treat back problems. A lot can be done to ease the pain—sometimes a lot more than is actually needed. New evidence about what works and what doesn’t is coming in all the time. Using this information, your doctor or other health care professional can make decisions that will give you the best care possible while avoiding the costs and health risks of unnecessary tests and procedures. This book will help you be part of this decision-making process.

About this Book This book will help you understand the causes of back pain and how it is diagnosed and treated. You will read about the “red flags,” which indicate that a serious problem may be present, and you will learn that “less is more” when it comes to treatment of simple types of back pain. You will read about computed tomography (CT) scans and magnetic resonance imaging (MRI), and you will learn when surgery is needed—and when it is not. You will find some advice on coping with a backache and read about some ways to prevent back trouble from arising in the first place. At the end of the book is a glossary of terms related to the back and its many problems.

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Contents 1. What Is Back Pain? 2. Who Gets Back Pain? 3. How Is the Back Put Together? 4. What Causes Back Pain? 5. How Is Back Pain Diagnosed? 6. How Is Back Pain Treated? 7. Are There Any Other Back Pain Treatments? 8. What Can I Expect Once Treatment Has Begun? 9. What Can I Do to Prevent Back Pain? Glossary

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CHAPTER ONE

What Is Back Pain? If you have suffered from back pain, you are not alone. This kind of pain affects over 70% of the American public at one time or another in their lives. Visits to the doctor for back pain are frequent, and chronic pain in the low back is the most common cause of disability for persons under 45 years of age. The costs of evaluating and treating low back pain are tremendous and are measured in billions of dollars.

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n this book, we will primarily focus on low back pain. We define low back pain as a nagging or aching pain in the lower spine, from the belt line to

the tailbone (Figure 1-1). This pain may be present for a few days or weeks. We call that “acute” low back pain. When pain has lasted more than 12 weeks and shows some signs of being an ongoing problem, we call it “chronic” low back pain. Making a distinction between acute and chronic pain can sometimes be helpful to doctors but the causes are often the same and making a distinction isn’t always necessary. It may be more appropriate to think of back pain as an ongoing part of the human condition, with periodic flare-ups and some happier times when the pain is not so bad or even gone. Fortunately, the really bad flare-ups tend to be few and usually go away— even without treatment—in a few weeks or months.

Are there other names for back pain? An old-fashioned term for back pain is “lumbago.” This word does not really have any special medical meaning. It is just a catchy way of describing the nagging pain we have already mentioned. Other terms for back pain often suggest explanations for the pain, whether or not they have been shown to

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apply in a particular person’s situation. This kind of thinking causes a lot of people to refer to their back pain as arthritis or back strain. They may also speak of having their backs “go out,” a description that implies some sudden misalignment of the spine as a cause of pain. We will see later how hard it is to understand back pain, and we will see that these descriptions may not always apply. Process

Vertebra Disc

Figure 1-1. This book primarily focuses on low back pain— nagging or aching pain in the lower spine, from the belt line to the tailbone.

Tailbone

Back Pain: Costs to Society • Over 70% of the American public suffers at one time or another • Back pain is the most common cause of disability for those under age 45 • Evaluation and treatments cost billions of dollars

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Is sciatica a type of back pain? Essentially, yes. Some people with back pain will have discomfort that shoots or “radiates” down the leg, often all the way into the foot or toes. This radiating pain is called “sciatica” (Figure 1-2). When people have sciatica it is often due, as discussed in later chapters, to irritation of one of the large nerves leading into the leg. It is this type of pain that many people refer to as a “pinched nerve.”

Sciatic nerve

Figure 1-2. Pain that shoots or “radiates” down the leg is called sciatica. Sciatica is often due to irritation of one of the large nerves leading into the leg.

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CHAPTER TWO

Who Gets Back Pain? Back pain usually begins after people have reached 30 years of age. People between 45 and 65 have the highest back pain rates of all sufferers. Because back pain is often related to overuse of the back or some other kind of straining or wear-and-tear process, it would seem likely that people who do a lot of physical work in their job or around the house would have more trouble than those who lead less strenuous lives. This is generally true, but anybody can have severe back pain, and it can occur after even minor overuse or no injury at all. People who are in poor general physical condition also tend to have more problems with pain and have a harder time recovering from it. You will see in the last chapter that trying to improve your physical condition is an important part of recovering from back pain.

Can being overweight cause back pain? Perhaps. Being overweight has been linked to the development of back pain, but there is no good proof that being overweight is the actual cause of the pain. No research has been done to determine whether losing weight will cause less back pain, although it would seem logical that it should.

Can smoking cause back pain? We are not sure. As medical specialists have seen with being overweight, there are research findings that show that smoking is associated with back pain. Again, however, there is no good evidence that smoking actually causes the pain. There is also no evidence that stopping smoking will

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eliminate back pain. There are, of course, many other good reasons for people to avoid being overweight and smoking.

Q A Q A

Are older people more prone to back pain? Not necessarily. Back pain can certainly occur in people in their later years of life. Sometimes these individuals are simply continuing to suffer the kind of pain that plagued them in their earlier years. In other cases, they can develop new kinds of pain that may have serious causes.

Are younger people more prone to back pain? Again, not necessarily. Back pain can occur before age 30 and is usually due to the same causes we see in people in middle age. There are, however, some special concerns in younger people who have back pain. They may have some congenital abnormality in the spine (a condition they were born with) or they may suffer a special kind of arthritis associated with some diseases that particularly affect young adults.

Back Pain: Who Gets It? • Any age, but most sufferers are 45 to 65 • Those who do a lot of bending or lifting • The overweight • Smokers

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CHAPTER THREE

How Is the Back Put Together? To understand the many possible causes of back pain, and understand how tests can be used to explain pain, it is necessary to begin with anatomy. The pictures and diagrams are as simple as possible to make things easier to understand.

T

he human spine is made up of a series of drum-shaped bones called vertebrae. These are stacked one on top of the other, like cans of tuna

fish on a supermarket shelf. They are separated from one another by shock absorbers called intervertebral disks or disks for short (Figure 3-1). These shock absorbers are not simple pads, like the felt pad you might find under your living room carpet. Instead, they are fibrous, almost leathery, on the outside with a soft jelly-like center—sort of like a 2-day-old jelly doughnut. If you can picture this, you will see why a problem can occur when a disk tears and the soft center material pushes out and puts pressure on nearby nerves. Also, our “doughnut” may also get so old and stale that it becomes more like a potato chip. Disks like this, which have undergone what doctors call chronic degeneration, can also cause back pain. Each vertebra has some additional bony structures that stick out on the back side of the spinal column to form a kind of arch. On the top of the arch is a bony “fin,” somewhat like the fin that sticks up on the top of a swordfish. This can stick out near the skin, and when you run your fingers up and down your spine and feel bony bumps, you are actually feeling the tips of those bony “fins.”

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The arches on the stacked-up vertebrae line up to form a channel through which the spinal cord runs. The spinal cord carries nerve signals from the brain to the rest of the body and is protected by being inside this bony channel. At each level of the spine, certain nerves branch off from the spinal cord and pass through the bony arch to go to the arms, legs, or other parts of the body. When there is some problem that presses on a nerve as it passes out of the spinal column, pain can result. As we will see, disk bulges and arthritis changes where the nerves are running are common causes of back pain.

Figure 3-1. Vertebrae and disks. We still have not talked about how the vertebrae are actually hooked together. The disk material we have already described connects each vertebra to its neighbors, but something more is needed. There are small, bony structures, like hooks, which are found on each of the arches of bone Vertebra

that surround the spinal cord. These arches connect to the hooks at the next level like

Disk

couplers in a railroad train. Like couplers, these connections, called facet joints, have some “give” that allows the neighboring sections of the spine to move and wiggle. This is what allows us to bend from side to side, forward and back, or twist the spine. Disease in these small joints is an example of a truly arthritic process that can cause back pain.

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There is one more part of the back that you should understand. The vertebrae that we have described are found in the neck, in the mid-back near the ribs, and in the lower back all the way down to the top of the pelvis. The lowermost sections of the spine are the sacrum and the coccyx, or “tailbone” (Figure 3-2). The sacrum is made up of a series of vertebrae that have fused into a solid bony mass in the shape of a triangle. This triangle is wedged between the two sides of the pelvis, completing a bony, basket-like structure that protects the lower internal organs. You can feel the top edges of your pelvis when you press down on what we sometimes call our “hip bones.” Our trip down the spine ends with the coccyx, which is a little bony point at the bottom of the sacrum. It usually does not have much to do with back pain, although it can certainly hurt if you land on it hard!

Sacrum

Sacrum

Tailbone

Tailbone

Figure 3-2.

The lowermost sections of the spine are the sacrum and the coccyx, or

“tailbone.”

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How Anatomy Can Influence Back Pain • Material in the disk’s center pushes out and puts pressure on nerves (disk herniation) • Disks can dry out (disk degeneration) • Nerves are squeezed as they pass out of the spinal column (spinal stenosis) • Joints become inflamed (arthritis)

Joints, called sacroiliac joints, are found where the edges of the sacrum meet the sides of the bony pelvis. Each is a joint in the sense that the place where two bricks joined by mortar might be seen as a joint. There is ordinarily no movement at these joints. In some diseases, however, as we will see later, a kind of arthritis or inflammation can develop in these sacroiliac joints.

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CHAPTER FOUR

What Causes Back Pain? Truthfully, most of the time we don’t really know. In fact, about 85% of back pain occurs without any obvious injury or any other clear cause that can be shown using radiography (x-rays) or other special tests. That does not mean that all the tests are always negative. We will see in later chapters that abnormalities are sometimes found. The problem is that it is hard to prove that they are the actual cause of the pain that a patient has.

D

espite the problems we have in explaining the causes of back pain, there is a lot that we do know. You should understand that doctors can

most help you by thinking about your back pain as having one of three general causes: • Mechanical • Nonmechanical • From some other medical cause or disorder Some of these causes are much more serious than others, and doctors and other health care providers who treat people with back pain need to watch for them carefully (Table 4-1).

What is mechanical back pain? By this term we mean pain that is, in most cases, due to stresses and strains put on the parts of the back we discussed in our anatomy lesson in Chapter 3. Common stresses and strains include the following: • Upright posture: The spine is naturally subject to stress because of our upright posture. This puts a load on the spine whenever we are up and about.

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Table 4-1: Common Diagnoses of Mechanical and Non-mechanical Back Pain Mechanical

Nonmechanical

Common stresses and strains (poor posture, being overweight, etc.)

Infection

Disk herniation

Cancer

Disk degeneration

Diseases that cause inflammation

Spinal stenosis

Psoriasis

Injuries/fractures

Inflammatory bowel disease

Compression fractures

Arthritis of the sacroiliac joints

Insufficiency fractures

Ankylosing spondylitis Bacterial infections of the sacroiliac joints

• Poor posture: In addition to being upright, things are not helped if you have poor posture. • Being overweight: As we discussed in Chapter 2, lugging around a waistline bigger than desired can influence or aggravate back pain. • Repeated bending and lifting (especially improper lifting). • Sagging mattresses. • Fatigue. • Emotional stress. When things get tough enough due to any of these stresses and strains, the spine complains with nagging pain. Although these factors all contribute to back pain, it is still very hard to know just which is the exact cause of a particular attack of pain. It is for that reason that we emphasize that most back pain is hard to explain. In these situations, general terms such as “back strain” are used but don’t really help much. It might be better to just call it acute low back pain and leave it at that unless a more specific diagnosis can be made.

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Can specific diagnoses of mechanical back pain be made? Yes. An individual can suffer from • disk herniation, • disk degeneration, • spinal stenosis, and • injury or fractures (compression or insufficiency). Let us look at each of these in depth. Disk herniation. This occurs when the fibrous outer part of a disk tears and the soft inner portion pushes out and puts pressure on nerves as they leave the spine to go into the leg. (Figure 4-1). There may be some inflammation (swelling and pain) in relation to this disk pressure, and that can make things even worse. This kind of disk problem is a common cause of sciatica, and the treatments that are needed are for both the inflammation and the actual nerve pressure.

Figure 4-1. A herniated disk occurs when the fibrous outer part of a disk tears and the soft inner portion pushes out and puts pressure on nerves as they leave the spine to go into the leg.

Disk degeneration. Disks can degenerate over time and become dried out, like the potato chip mentioned in Chapter 3, and that is also thought to be associated with back pain. Spinal stenosis. This is a special kind of mechanical problem in the spine that is actually a narrowing of the channel, or spinal canal, where the spinal cord runs. It can be caused by overgrowth of the bony facet joints, by swelling of the big ligaments that

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Soft inner part of disk pushing onto spinal cord

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Spinal cord

Normal

Stenosis

Figure 4-2. Spinal stenosis is a narrowing of the spinal canal.

run near the spinal cord, by disk herniations, or by some combination of these factors. When this condition, called spinal stenosis (Figure 4-2), involves the lower (or lumbar) spine, the spinal cord is not directly affected because the spinal cord actually ends at a somewhat higher level in the back. A larger bundle of nerves, however, runs down through the rest of the spinal canal, with each nerve then spreading out to the legs. Stenosis in the lower part of the spine will put pressure on this nerve bundle. (Stenosis higher in the spine can put pressure on the spinal cord itself.) Injuries or fractures. A fall or an automobile accident can cause a break in the bony arch surrounding the spinal cord, or a break in one of the small “fins” that stick off of the arch. Some of these fractures cause a lot more trouble than others. The most common fracture of the spine, however, is a compression fracture. This occurs when there has been a jarring up and down along the axis of the spine. Falling on the ice and landing on your bottom, or bouncing on a snowmobile, can cause this kind of fracture. The result is what doctors call a “collapse” of a solid bony vertebra. Sometimes the vertebra gets flattened almost out of existence. This collapse can occur, without any prior injury, in people who have very thin bones, and is a common cause of discomfort in both the low back and higher—in the thoracic spine—in elderly people with osteoporosis.

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Another consequence of thin bones (and a cause of pain in the low back) can be a fracture in the solid sacrum, or in one of the bones in the pelvis. Because the bone is weak, or insufficient to do its job, we call these insufficiency fractures.

What is nonmechanical back pain? Nonmechanical back problems are not simply due to wear-and-tear. Examples include • infection, • cancer, or • diseases that cause inflammation of the usually solid “joints” between the sacrum and pelvis. Let us look at each of these in depth. Infection. An infection in the spine commonly involves a disk and extends into the bone on either side of the disk. This kind of infection can occur after blood poisoning or during heart infections, but can also occur with conditions such as tuberculosis. Cancer. Cancer can spread from other places in the body and get into the bones of the spine. This can cause severe pain and sometimes affect the function of the nerves or spinal cord. There is also a kind of cancer, called multiple myeloma, which starts in the bone marrow within the vertebral bodies and can cause them to collapse. This can look a lot like the compression fractures discussed in the previous answer. Doctors who treat back pain are well aware of this sort of thing and know when and how to test for it. Certain diseases can cause inflammation in the usually solid “joints” between the sacrum and pelvis. These sacroiliac joints can become painful, and there will be serious stiffness in the back in people with diseases like • psoriasis, • inflammatory bowel disease (ulcerative colitis and Crohn’s disease),

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• arthritis of the sacroiliac joints, which can result from certain sexually transmitted diseases or occur after intestinal infections, • ankylosing spondylitis, which usually affects young men and has a particular tendency to involve the sacroiliac joints. This condition can also cause stiffness in the rest of the spine and trouble with moving the ribs properly during breathing, or • bacterial infections that can get into the sacroiliac joints. In these cases, however, the trouble is usually on one side only. All of the other conditions tend to affect both sides.

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What else can cause back pain? Fortunately, the following are all rare, but they can cause back pain: • Diseases in the abdomen or pelvis • Kidney stones or kidney infections • Ulcers, problems with the pancreas, gallstones, and tumors, • An abdominal aneurysm—a stretching of the large artery in the abdomen that can have very serious consequences. Doctors who see patients for back pain need to consider all these possible causes.

Q A

Which conditions cause the most back pain? Almost all cases of back pain are due to mechanical causes. 70 or 80% of those cases involve the unexplained discomfort we have discussed so much. Another 10% may be due to degeneration in the disks or in the facet joints. Approximately 4% of back pain problems are due to disk herniations, and only a very small number of those people actually need to undergo surgery. Fractures due to osteoporosis occur in a similar percentage of people; spinal stenosis is even more rare. Problems such as tumors, infections, and inflammation in the sacroiliac joints make up no more than 1% of the cases of low back pain that we usually see. Up to 2% of back pain is due to pain coming from internal organs. Those cases

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usually involve kidney disease, including kidney stones and infections, and are relatively easy to recognize. Back pain is only rarely due to other serious abdominal problems or aneurysms. Figure 4-3 is a good representation of which conditions cause the most back pain.

Fact: Doctors cannot pinpoint the exact cause of back pain 85% of the time.

Unexplained Fracture

Internal organs

Disk degeneration

Disk herniation

Tumor, infection, sacroiliac joint inflammation

All others

Figure 4-3. Frequency of conditions causing back pain.

What causes most back pain in older individuals? We mentioned in Chapter 2 that there are some particular problems that can cause back pain in older people: • Compression fractures of the vertebrae are a frequent cause of back pain in older people with osteoporosis.

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Age and the Back Younger • Disk problems (from lifting or straining) • Sacroiliac joint diseases OLDER • Compression fractures • Osteoporosis (leading to fractures) • Spinal stenosis • Abdominal aortic aneurysms • Paget’s disease

• Insufficiency fractures, which you will remember are cracks in the sacrum or pelvic bones due to osteoporosis, can also cause severe pain, but they almost always heal by themselves and rarely have long-term consequences. • Spinal stenosis is pretty much a disease of older patients, although it can sometimes affect young people if they have disk herniations or other reasons for a narrow spinal canal. • Abdominal aortic aneurysms are usually found only in older people. An enlarging or leaking aneurysm is an unusual but very serious cause for new low back pain in a person later in life. • Paget’s disease can also cause back pain in older people. It is a disorder that results in the formation of a very thick-looking, but unhealthy, bone. The bone looks very dense on x-ray films and the condition can be very painful. Overgrowth of bone in Paget’s disease can also cause pressure on nerves or cause spinal stenosis to develop.

What causes most back pain in younger individuals? Young people certainly can get the usual types of backaches we have talked about, and they can have disk problems if they do a lot of lifting or straining. The diseases of the sacroiliac joints that we have discussed, however, are particularly likely in younger patients. Doctors need to consider those diseases when people under age 30 have chronic back pain.

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CHAPTER FIVE

How Is Back Pain Diagnosed? We will start from the premise that most back pain is caused by simple, usually mechanical, factors. The pain can be very annoying, but there are usually no serious implications. Patient history and a simple office examination will usually be enough to understand what is going on. X-ray films are generally not needed, but x-ray films and tests, such as computed tomography (CT) scans and magnetic resonance imaging (MRI), may be needed if there is concern about an infection, a tumor, or a serious nerve problem. Bone scans or evaluations of the abdomen and the internal organs may sometimes also be needed. (These tests are all described later in this chapter.) Also, Table 5-1 is a quick reference list of the procedures used for diagnosing back pain and describes when they are used.

A

lthough it is very important for doctors to consider and judiciously rule out the many serious causes of back pain, it cannot be overemphasized

that most back pain is of simple—if poorly understood—origin. Most people do fine with simple evaluations, and going on a long search for some mysterious cause of pain is rarely helpful. That kind of thing can put people at risk for complications and distract everyone from working on improvements in function and overall health that will be much more helpful in the long run.

How do I know if I should go to the doctor? It will help if you know about some symptoms associated with back pain so you will know when to ask for help. You should see a doctor for the following reasons:

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Table 5-1: How Back Pain is Diagnosed Procedure

Used when…

Physical examination

Patient first visits the doctor for back pain

Radiography (x-rays)

Fracture or infection is suspected; otherwise usually unnecessary and inconclusive

CT scan/MRI

“Red flags” are present indicating possible tumor, infection, organ involvement, disk herniations, etc.

Myelography

Spine and its nerves must be seen

Bone scan

Bone damage, infection, or tumor is suspected or confirmed

Diskography

Disk problems arise, but only in special situations; controversial

Blood tests

Infection, tumor, or systemic illness is suspected

Electrical tests (electromyelography)

Nerve diseases need to be recognized, or when pressure on nerves that might be caused by disk problems or spinal stenosis must be seen

• Pain occurs right after a fall or other injury. This could be serious because a fracture is possible. • You have pain, numbness, or tingling running down one leg, especially if it is worsened by coughing or sneezing. This suggests that a nerve has been irritated by a disk problem. This is particularly troubling when there is some weakness associated with the pain. If you have trouble lifting a leg to get in and out of the car, to get up on a curb, or to climb stairs, it can be a sign of a serious nerve problem. • You experience not only pain in the lower back, but also an aching or numbness down either or both legs. This usually signals spinal stenosis. This is usually worse with walking, standing, or bending backwards.

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Leaning forward tends to relieve the problem. When a person with spinal stenosis walks too far, and experiences leg pain, he or she will usually need to sit down to get relief. When people over age 50 have this kind of distress, spinal stenosis must be considered. • You experience not only back pain, but also trouble emptying the bladder and numbness in the area between the legs where you sit. This could signal a very large disk protrusion, or a tumor or infection, which puts pressure on the entire nerve bundle as it runs downward through the spinal canal. These symptoms represent an emergency situation. • You experience back pain and have taken corticosteroids (cortisone-like medications) or have used intravenous drugs. This could be an indication that you have a compression fracture or an infection. Fever can be a tip-off to the presence of infection. • Your unexplained severe back pain is accompanied by weight loss, fatigue, or other awareness that your health is failing, especially if you are over 50 years of age. Also, if you have a personal history of cancer, the occurrence of back pain is always of concern because it could mean that the cancer is recurring in a way that involves the bone. You should be able to see from this discussion that the assessment of back pain depends a lot on who has the pain, how severe it is, and what symptoms go along with it. Your doctor will recognize some of the worrisome features mentioned and may refer to them as “red flags.” These are tip-offs that something more serious is going on and that further testing is important.

Common Doctor Questions • Are your work and daily activities affected? • Have you tried any treatments or medications? • What makes your pain feel better or worse? • Are you satisfied with your work? • Are you stressed, depressed, or angry?

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.

What else will my doctor want to know? Your doctor will want to know how the back pain affects your ability to work. He or she will review the tasks you undertake at home or on the job and consider how these activities might contribute to your pain. Your doctor will need to decide whether your work can safely be done while you have pain, and will need to assess if some change in your activities would be helpful in preventing further problems. There are some further aspects of the relationship between work and back pain that we also need to talk about. Back pain can be particularly troublesome for people who do not like their work, feel that they have little control over their work situations, or feel unappreciated. Research has shown a strong connection between low job satisfaction and the occurrence of back pain. Research has also shown that there is an association between a person’s private life and the risk of developing a more chronic pattern of back pain. Stress, depression, anger, and a passive attitude (with the expectation that a pill or other treatment will do the trick without a patient’s active participation in his or her own recovery) are all predictors of chronic problems. Because of this, professionals who help patients with back pain sometimes need to ask sensitive questions. The more they understand, the

Q A

more they can help.

Is there anything else I should make sure my doctor knows? Yes. If you need to see your doctor about back pain you will also need to let him or her know what medications you have tried, what has helped and what has not, how long the pain has been present, when it is bad, and whether it is getting better or worse. Pain that is worse with inactivity or worse at night can be of real concern and your doctor will want to know about it.

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What type of physical examination should I expect? How much examination is needed and what testing may be ordered depends almost entirely on the history that you give to your doctor. Examination can be pretty simple if he or she doesn’t note any red flags. At a minimum, your doctor will want to • look at your back to check for curvatures and deformities, • thump on the spine to see if there are tender places, and • ask you to bend and twist to show how flexible your spine is. The examination will be more detailed (and more special testing may be needed) if there are worrisome features. Tests performed (or ordered) may include the following: • The “straight leg raising test” to test for sciatica. As its name describes, the test involves raising the legs and checking for pain. Your doctor will know how to interpret the findings and help you understand whether or not a nerve irritation is present. • A test of strength and sensation in your legs and feet and reflexes at your knees and ankles. Combining the results of these observations will allow a very reasonable estimate of the likelihood that a serious disk problem is affecting a nerve. If a person with back pain has no pain going all the way down the leg, has normal findings on the straight leg test, and has normal strength and reflexes, the chance of a serious nerve problem is very, very low. • A neurological exam may be needed when there are other signs of problems with the nervous system, such as trouble with bowel or bladder control, or more serious patterns of numbness. • An abdominal, rectal, and/or pelvic exam may be needed if there is concern that the pain is due to a problem in the abdomen or pelvis, such as a kidney infection or aneurysm. • A complete physical exam could be needed if your doctor suspects that the pain you have could be related to a more generalized or “systemic” illness, such as cancer or an infectious illness.

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See the Doctor If You Have the Following: • A fall or injury • Pain, numbness, or tingling in the leg(s) • Trouble emptying your bladder • Back pain and you take corticosteroid or intravenous drugs • Back pain and sudden weight loss and fatigue • A history of cancer

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Will x-ray films show all back problems? No. You might think that a back x-ray film would be important in understanding back pain, but back x-ray films usually do not help much. People with the usual kinds of simple backache generally have normal x-ray films. Regular x-ray films cannot recognize pressure on a nerve or the presence of spinal stenosis. X-rays also expose people to the risks of radiation, and if minor abnormalities are found, it is hard to know if they are actually causing pain. Even people with no pain at all may have x-ray films that show bone spurs and other minor findings. X-rays are usually not needed during the first month or two of backache as long as there are no red flags.

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When should x-rays be done? When there are red flags, and especially after an injury or some other circumstance that suggests bone damage, simple x-ray films can be helpful. Compression fractures, infections, and some kinds of tumors can be recognized. In worrisome situations, additional tests may be needed if the regular x-ray films are not helpful.

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When should I have a CT scan or MRI? A CT scan is a way to take cross-sectional pictures of the spine using radiography that produces regular x-ray pictures. A computer puts the views together to create a detailed picture. MRI produces similar pictures but is done without using regular radiograph radiation. Instead, the person having the examination is placed within a harmless magnetic field that causes

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special signals to arise from the tissue of the back. These signals are processed to give very detailed pictures showing the bone, muscles, and most importantly, the spinal cord and nerves. These techniques can show pressure on the spinal cord, disks pressing on nerves, tumors, and other important findings that would not be recognized on regular x-ray films.

If CT scans and MRIs are so helpful, shouldn’t everybody with back pain have them? The majority of people do not need these special tests. Most back pain, as we have emphasized, is not due to any structural problem that can be recognized on pictures, and most people get better with simple treatments.

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These tests are complicated and expensive, and if they were done for everyone it could mean a delay in getting an important examination for the person who really needs one. These special tests are also plagued by the same problems we have described with regular radiography. There are lots of disk bulges, minor bone spurs, and other seemingly “abnormal” findings discovered during these exams that don’t really explain anything. Overemphasizing these “diagnostic” findings can lead patients and their doctors to think a cause for pain has been found when that is not the case.

When are CT scans and MRIs needed? CT or MRI examinations are usually needed when • there is a concern about an infection or a tumor; • there is concern about some serious nerve problem affecting the legs, bowel, or bladder; • spinal stenosis is suspected or confirmed; • disk herniations and pressure on nerves is present. In this situation, however, the tests are only needed if there is severe weakness, unrelenting pain, or if surgery is being considered; or • a case is puzzling or difficult, when the history is confusing, or the pain is not improving. These tests may help clarify the situation, but if they are

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negative, the likelihood of a serious problem being present is, of course, much less. In general, these tests are not needed for sciatica because just proving that there is nerve pressure may not help much in the absence of weakness. Plus, sciatica can generally improve without special treatment.

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Are there any other special tests that might be done? Yes, and they are described below. Myelography. Myelography is a long-established way of looking at the spine and its nerves that involves injecting a dye into the spinal fluid that surrounds the spinal cord. MRI has mostly replaced this test but it is sometimes still needed, particularly in people who are unable to have an MRI examination. Sometimes dye is put in the spinal fluid and then CT pictures are taken. This combined technique is called CT myelography. This can be helpful in certain special situations. Bone scans. A bone scan provides doctors with another way to examine the skeleton. In this test, a harmless radioactive substance is injected into the bloodstream and settles into the bone. Places where there is bone damage, infection, or tumor growth will then show up on pictures of the skeleton taken with a special camera. These images do not show a lot of detail and a bone scan is not usually as helpful as an MRI, but there are special situations in which bone scanning can be useful. The bone scan can be helpful in showing when there is a tumor that has spread through the skeleton. When there is a subtle fracture, especially an insufficiency fracture, the bone scan shows the problem. These insufficiency fractures may not be seen at all on plain x-rays, and may be hard to recognize even on a CT scan, but show up well on bone scans. Diskography. Diskography is a way of testing for problems in the disks between the vertebrae. This test involves the injection of some material into a disk, and if the patient’s back pain is reproduced, then it is often concluded

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that the disk in question is the cause of the person’s pain. This test is controversial and is used only in special situations. Blood tests. If your doctor suspects an infection, tumor, or some systemic illness as a cause of pain, then he or she may need to order blood tests to better understand the situation. If there is a concern about a problem in the abdomen, your doctor may need to check your urine, or do x-rays, CT scans, or ultrasonographic examinations of the kidneys, gallbladder, or pelvic organs. This kind of testing is rarely needed. Electrical tests. The function of the nerves in the legs can be tested by putting small needles into the muscles of the legs in a procedure called electromyelography. This kind of testing can recognize nerve diseases and pressure on nerves that might be caused by disk problems or spinal stenosis. Most people with back pain do not need this testing, but it can be helpful if the cause of leg pain is unclear.

How do I know if I should see a specialist? It depends. What you need most if you have back pain is a trusted and knowledgeable practitioner who can consider everything we have discussed here. He or she can then work with you to decide what testing and treatment is appropriate. This doctor could be either a specialist or a primary care physician. In many cases, a primary care physician can provide all the care that is needed. Some problems, of course, will require a specialist’s help. In general, people need to see specialists when they require surgery, have an uncertain diagnosis, or are not improving despite appropriate treatment. People with disk problems who seek surgical relief will need to see an orthopedic surgeon or a neurosurgeon. Steroid injections, discussed in Chapter 6, are usually done by anesthesiologists. If a doctor suspects infection, cancer, or some other serious problem, he or she will order the testing and consultations your problem requires. In this situation, the special care needed will go outside the scope of this book.

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CHAPTER SIX

How Is Back Pain Treated? When there are no red flags, simple measures will help most people with back pain. In fact, most people with back pain will get better in a few weeks without any treatment at all! Even people with sciatica will get better, but that can take longer—sometimes up to 3 or even 6 months.

T

he treatment of back pain, then, begins with education. If you have back pain, you need to understand the likely causes. Furthermore, when

there are no warning signs of a worrisome condition, you need to be reassured that you have a condition that will quickly improve in most, but unfortunately not in all, cases. You need to understand that x-rays and special treatments are usually not needed, for reasons we have already discussed. You also need to understand some simple measures that can help you during the greatest discomfort and that you can usually resume work or other activities with very little risk even if the pain is not entirely gone. If you understand all this, you are in the best position to work with your doctor to achieve a satisfying outcome. Table 6-1 is a quick reference list on the common treatments for back pain and whether or not they are helpful.

Will bed rest help? Not really. For decades, doctors have recommended bed rest to help people get through attacks of back pain. It turns out that this isn’t such a great idea. Too much bed rest can cause people to get weak and have even more trouble regaining normal function. Research studies done in recent years have

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Table 6-1: Treatment for General Back Pain Treatment

Helpful?

Bed rest

No

Exercise

Yes

Physical therapy

Yes

Chiropractic treatment

Yes, as long as there are no red flags

Osteopathic treatment

Yes

Medications Acetaminophen Ibuprofen Muscle relaxers Narcotics Antidepressants

Yes Yes Yes, with caution Yes, with caution Possibly

Massage

Yes

Acupuncture

Possibly

shown that 2 days of bed rest is more than enough for most people with back

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pain. And, if possible, bed rest should be avoided altogether.

So should people with back pain remain active? Yes. Research has shown that people who remain active during their acute pain episodes actually have less future pain and need less health care than people who rest and wait for the pain to disappear. A study of city workers in Finland showed that people who kept going as much as possible got better faster, and with better long-term outcomes, than those who had various periods of rest or special treatments.

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Can physical therapy help? Many people get better so quickly that formal physical therapy is not really needed. If the discomfort lasts for more than a few weeks, however, physical therapy is appropriate. Therapists can ease sore muscles with special treatments, can help with posture and flexibility, and can offer help in strengthening the back to prevent further pain.

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Does exercise help? There is a lot of evidence that exercise is an important factor in the prevention and treatment of back problems. The best exercise programs improve general aerobic fitness while strengthening the back muscles. You can do simple

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exercises to maintain general fitness even during acute pain as long as the exercise is tolerable and has been judged safe by a physician. You can then undertake training to improve strength and flexibility of the back muscles once your pain has subsided. This can help a great deal in preventing recurrences or “relapses” of back pain. Exercise is discussed in detail in Chapter 9.

Should I see a chiropractor? Chiropractic practitioners, commonly referred to as chiropractors, see many people with back pain. In some settings, more than two-thirds of the people who seek chiropractic care are hoping for help with back pain. Chiropractors

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are trained to understand the causes of back pain we have discussed, and should be familiar with the red flags that indicate serious conditions. When there are no signs of worrisome problems, chiropractors can treat back pain with a variety of manipulative treatments.

Some research has shown that people who get chiropractic care do as well as people who receive physical therapy or medications. In many cases, they actually seem more satisfied after chiropractic treatment. Thorough explanations of the treatment given, and the provision of self-care advice, characterize the chiropractic care in these research situations and seem to be the main reasons why the patients were so pleased.

Can osteopathic treatment help? Osteopathic physicians are licensed to provide a full range of medical care. They can prescribe medications or do surgery, if necessary, and they often treat back pain in just those ways. But osteopathic physicians also offer treatments, called osteopathic manipulative therapy, which may be helpful in treating back pain. These treatments involve manipulating the muscles and soft tissues to enhance healing. In studies comparing osteopathic

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manipulation to other medical approaches, there was no difference in outcome or satisfaction after 12 weeks of treatment.

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What medications can help? The following medications can all play a role in treating back pain and all are discussed more thoroughly below: • Acetaminophen (Tylenol®) • Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen • Muscle relaxers • Narcotics • Antidepressants Acetaminophen (Tylenol®). Acetaminophen (Tylenol®) is effective for back pain and is usually safe and certainly inexpensive. For those reasons, it is a good first choice if you want to use a medication. Nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs, such as ibuprofen, are helpful both for relieving pain and for reducing any inflammation that may be contributing to the pain. Research show that these drugs are effective, but we don’t know if one is really better than another. Side effects include stomach irritation, intestinal bleeding, fluid retention, and risks to the kidneys and liver. Regardless of which NSAID you choose, these drugs are usually safe and helpful in the short term, but their use needs to be carefully monitored if they are taken over longer periods of time. Muscle relaxers. Muscle relaxers are often used for back pain but there are some problems with using them. Although there is some evidence that they are helpful in reducing discomfort, they can cause drowsiness and may be unsafe in people who need to drive or use machinery. Most physicians who treat back pain would consider them second-line drugs.

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Narcotics. Opioid drugs (narcotics) are effective for treating many kinds of pain but their use in back pain is controversial. Occasionally, patients with acute episodes of back pain have so much discomfort that they need an opioid drug for relief. Usually, however, other safer medications can be sufficient. The role of narcotics in people with chronic back pain is even more complicated. Some patients do benefit from taking opioids, but a decision to undertake that kind of long-term treatment requires careful thought and consultation. Antidepressants. As we have seen, there are people with back pain problems who are dissatisfied with their work or life situations. This dissatisfaction can promote an ongoing problem with back pain, and it would seem that helping these people with antidepressant medication would be a good thing. Whether that treatment will help backache itself is harder to say. The research on this is unclear and, as with narcotics, a decision to use this kind of treatment for back pain needs to be made on an individual basis.

What is the treatment for sciatica? For people with sciatica due to a disk herniation, there are usually two approaches that can be taken. Conservative care with provision of appropriate medication to reduce pain and inflammation is often enough. Most people with sciatica will improve in 3 to 6 months. Even very bad episodes of sciatica can go away and stay away. People with severe weakness, on the other hand, usually come to surgery pretty quickly because of a belief that relieving pressure on the nerve will correct the weakness and prevent later disability. There are some patients with sciatica who fall “in the middle,” so to speak. They are not in enough trouble to need urgent surgery but they have such difficulty that it becomes hard to continue to treat them with what doctors call “watchful waiting.” These people may be offered either steroid injections or surgical relief.

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Steroid injections involve the placement of cortisone-like medications, often along with local anesthetics, into the area where a disk is pressing on a nerve to the leg. This is done by inserting a needle, in much the same way that a spinal tap is done. This kind of treatment is provided in hope of giving relief without surgery. There has been some research on the value of steroid injections to treat sciatica. In one study, patients were given either steroid injections or injections of harmless salt water, and after 6 weeks the leg pain was better in the group that received steroid medication. By one year, however, there was little difference, so it seems that the steroid injections have an immediate benefit but not a long-term one. To eliminate the need for injections, some doctors give steroid medications as oral tablets. This sounds as though it could work, but there is very little research on this topic, and what there is indicates that these pills do not help as much as one might hope. Surgery might be the answer for a really tough problem with sciatica in an effort to help with pain that just will not go away. Experience has shown that the people in this situation do feel better in the weeks and early months after surgery. But in later years things turn out the same in terms of ability to work and remain free of back pain recurrences.

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What is the treatment for spinal stenosis? The diagnosis of spinal stenosis is made more and more frequently as people with back pain undergo magnetic resonance imaging. Spinal stenosis is fairly common in older patients, although it may not be the cause of back pain. When there are severe symptoms that radiate down the legs, however, something should be done. In some cases, physical therapy and regular exercise can be helpful. Steroid injections also seem to help symptoms from spinal stenosis, and in extreme cases, surgery can be done to relieve the narrowing and take pressure off the affected nerves. As a general rule,

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surgery is not recommended when the narrowing is a coincidental finding that doesn’t seem to be related to disabling symptoms.

Are there any other treatments that should be mentioned? Yes. Massage. Almost as many back pain sufferers seek help through therapeutic

Q A

massage as seek assistance from chiropractors. Research has shown they are similarly satisfied, and seem to do as well or better than those who receive conventional medical treatments. Therapeutic message seems to work best for subacute or chronic back pain, and is safe as long as there are no red flags. Acupuncture. The benefits of acupuncture have also been studied, but the results have not been as positive. In one comparison of massage with traditional Chinese acupuncture, the acupuncture was judged to be “relatively ineffective.” Miscellaneous treatments. There are many other treatments suggested for back pain. Some have been shown to be worthless but, more commonly, the research needed to test these treatments has been poorly done, or has not been done at all. Medicine has a long way to go in this regard. So it may be better to admit that the value of many of these treatments is simply not yet known. Some of these unproven approaches include • injection of tender spots (known as trigger point injections), • traction, and • steroid medication taken by mouth. Despite scientific uncertainty, some of these measures do seem to help individual patients, and there will be people who swear by them because they feel they have been helped.

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Is there any treatment that works best? Many treatments seem to help back pain, but no one treatment is so clearly so superior to the others that it has come to dominate the scene. Table 6-1 lists all the common treatments we have just discussed. Medical practitioners tend to emphasize prescription and over-the-counter drugs. Chiropractors, and some osteopathic physicians, emphasize manipulative treatments. All agree that maintaining function is important, and that people should remain as active as possible and undertake appropriate exercise and fitness programs as part of a complete program of back care. We have mentioned that no one treatment is really best. The research in this regard is fascinating. A study that we mentioned earlier was done at the University of California at Los Angeles and showed identical outcomes at 3 and 6 months for people who received medication, physical therapy, or chiropractic manipulation. This suggests that the treatments were equally helpful, but whether most of these patients would have improved by themselves anyway remains an intriguing question. In another study, comparisons of chiropractic care and physical therapy also showed little difference in outcomes. But in that study, a third group of patients received a simple self-help brochure as the only treatment offered, and all three groups had the same good outcome! Of course, if people with back pain do get better after a particular treatment, it is human nature to give credit to the treatment that was given and many people believe deeply in the benefits of treatments they have seen as helpful.

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CHAPTER SEVEN

Are There Any Other Back Pain Treatments? There are treatments for back pain other than the ones described in Chapter 6, but most of these treatments (described below and shown in Table 7-1) are reserved for people with difficult pain problems. A conservative approach is still best for people with the usual kinds of back pain.

What are these other back pain treatments? They are surgery, artificial disks, and injecting cement material. Let’s discuss each in more detail. Surgery. Surgery is sometimes used for people with degenerative changes in the disks between the vertebrae. This surgery often involves what we call spinal fusion. Bone grafts, metal screws, and other devices are used to solidify the spine. The hope is that stabilizing the spine will reduce pain. A disk that is shown to be painful during the test called diskography (which we described in Chapter 5) is particularly likely to be the target of a fusion procedure. Spinal fusion is becoming more and more popular, in part because ingenious new techniques are now available. But how much these fusions help is still not as clear as we would like it to be. Spinal fusion can be of great benefit, but people considering this surgery need to understand as much as possible about the risks and benefits before going ahead. For people with spinal stenosis who have severe and disabling trouble despite medical treatment, surgery is often necessary. In most cases, a procedure called a laminectomy is performed. This involves removing the

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Table 7-1: Advanced Treatment of Back Pain–When Conservative Therapy Is Not Enough Surgery • • • •

Spinal fusion Laminectomy Artificial disks Injection of cement material into the vertebrae

Comprehensive pain management/rehabilitation • Implantation of nerve stimulator • Implantation of pump to deliver pain medication directly to source of pain

bony arch over the spinal canal. If the stenosis is associated with a slippage of one vertebra on its neighbor (a condition called spondylolisthesis), then a fusion procedure may also be needed. Artificial disks. If you think about it, fusing a spine for back pain makes about as much sense as fusing a knee to treat severe arthritis. It may reduce pain, but it eliminates normal movement, and sometimes just transfers the wearand-tear process to neighboring vertebrae. Because many of the back problems treated with fusion involve bad disks, experts have tried to develop What If Nothing Works? Sometimes nothing does. For these cases, comprehensive pain management or rehabilitation programs.

disk substitutes, made of metal and plastic, which can relieve pain without those drawbacks. Some of these replace the entire normal disk while others replace only the soft “nucleus,” or core, of the disk. These artificial, or “prosthetic,” disks have been used in Europe for about 10 years, and have a pretty good track record. Things look promising, but these devices are still under development, and their role in the care of back pain patients remains to be seen. Injection of cement material. For people who have had a compression fracture, usually because of osteoporosis or an injury, there is a promising new treatment available. This involves injection of a cement material into the collapsed vertebral body. The cement expands the bone, restoring some of its shape, and pain may be relieved.

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What if nothing seems to help my back pain? It is sad to say, but there are some people who have unrelenting pain for which even these advanced treatments are not helpful or appropriate. For these people, there are comprehensive pain management and rehabilitation programs. These programs involve thorough attention to all pertinent medical issues as well as to psychological factors and social concerns. Intensive treatment with an emphasis on improving function helps people get more out of life, although they may still have some continued pain. We have also seen how back pain can be related to stress, job satisfaction, physical fitness, and personal attitudes and expectations. It is logical, then, that people with difficult back pain problems should have comprehensive attention to all those aspects of their lives. For a small number of patients with severe and unrelenting pain, there are some other pain control measures that may help. For people with pain related to nerve irritation, a specialist can implant a nerve stimulator. This device will electrically stimulate the nerves and relieve discomfort. For people with more mechanical causes of chronic pain, specialists can implant pumps that deliver pain medication directly into the spine. This relieves pain without putting people at risk for the side effects that would occur if similar medication were taken by mouth. These extreme measures are reserved for people who have had complete evaluations and who have been fully informed about the chances of success. We are learning more about these kinds of specialized treatments all the time, and the place for these treatments in the care of back pain sufferers will become clearer as time goes by.

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CHAPTER EIGHT

What Can I Expect Once Treatment Has Begun? A good program of back care involves a relationship between you and the people treating you. You should expect information on or be sure to ask questions about • the likely cause of your back pain, • how long the pain can be expected to last, • the findings on your history and examination that have led your doctor to make these determinations, • how much activity is permitted, • whether any bed rest is recommended, • any medications provided or prescribed, • whether any additional treatment such as physical therapy will be provided if needed, • when you are to have a follow-up visit, • the kind of symptoms to watch for so that you can help your doctor know if something more serious is going on, • how likely it is that your pain will recur, • any preventive measures that might be helpful, and • whether your back pain problem will interfere with your employment. Working through these concerns with your doctor will make you a betterinformed patient and allow you to take a more active role in your own recovery.

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How long will my pain last? People with “garden-variety” back pain recover very quickly. One research report shows that 90% of people with this type of pain will recover within 2 weeks. Other studies, which tend to be more realistic, show that two-thirds of patients like this will be better after 2 months. But some may still have trouble after 6 months, and periodic recurrences are not uncommon. This leads us to realize that simple back pain is part of the human condition rather than something that can be seen as a one-time problem with a simple cure. People with herniated disks also get better, but it takes longer. For people with sciatica, most are improved after 6 months but about 10% will have ongoing problems. Spinal stenosis tends to be a chronic problem. A small number of people get better with exercise and weight loss, but some, perhaps 15%, have progressive trouble as the years go by. Although most back pain patients do improve, there are some who have ongoing and disabling trouble. In general, the longer a person has pain, the less likely it is that there will be complete relief. As we have mentioned, people who do not like their work or have trouble with the stress of life often have more of this kind of chronic difficulty. Table 8-1 describes most types of back pain and when relief comes.

Table 8-1: Back Pain: Who Gets Better? Type of pain

How long until recovery?

“Garden-variety”

Two-thirds will recover within 2 months

Sciatica from herniated disks

3–6 months

Spinal stenosis

Chronic for most people; 15% have progressive trouble

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What can I do to better get through my pain? Awareness that your condition is likely to improve will go a long way toward helping you through your pain. The reassurance that a careful examination provides and a professional explanation of the findings are also helpful in

Q A

relieving anxiety about the future. Knowing that a serious or dangerous cause is unlikely can also relieve worry and allow you to get on with your recovery. There is more and more evidence that people get better faster if they maintain their normal activities as much as possible. Taking to bed or withdrawing from normal activity weakens the muscles and tends to perpetuate pain. Keeping active really helps!

Won’t being active just increase my pain? Maintaining activities may be uncomfortable, but there is good evidence that it will not hurt you. In other words, you may have to put up with some pain in order to get better more quickly. The important thing to remember is that there can be a big difference between what hurts and what is dangerous. Just because walking or continuing your job is painful does not mean that it is causing harm. But we cannot oversimplify this. There can be circumstances in which continued activity is risky. That is why you and your doctor need to discuss what is safe—and what is not—in planning your treatment. If you have “garden-variety” back pain, you will do much better if you remain as active as possible.

Working Through the Pain In most cases of back pain: • Stay positive—most conditions improve • Trust your doctor—be reassured after a careful examination • Stay active—research proves this helps

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Should I do specific exercises? It depends. A program of gradual exercise supervised by a physical therapist or other exercise expert is usually safe and helpful, even during an acute attack of pain. How much exercise you should undertake on your own is less clear, but it does look as though you can begin light exercise as soon as it is tolerable. You can walk or swim at first, then add exercises to strengthen the upper body, and eventually the lower back, during the following weeks. If any of this causes severe discomfort, you should stop the exercise program until you can get professional advice. More information on exercise is in Chapter 9.

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Is there any advice on sitting or sleeping? There is some advice on both, and even more details and diagrams are in Chapter 9. Sitting. Poor body positioning can cause real problems for people who already have back pain. When your back is sore, you should take particular care to sit against the back of a firm chair at such a height that you can maintain a 90˚ bend at the knee with your feet flat on the floor. Slumping in a deep chair can make back pain a lot worse. Lying down. When you are lying down, you will feel better if you lie on your side with a low pillow under your neck and perhaps another pillow between your knees. If you lie on your back, put a thin pillow under your neck. Bending your knees may also help a little. Never sleep on your stomach, and when you do get up, it is best to get onto your side and then drop your legs over the edge of the bed before sitting up. Most people figure this out for themselves pretty quickly.

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CHAPTER NINE

What Can I Do to Prevent Back Pain? You can do a lot. Being in tune with your body by paying attention to the way you stand, move, and work will help. Reducing your stress level and making sure you get enough exercise and the correct type of exercise will help too. This chapter has information on all of these topics. At the end of the chapter, you will find a back care checklist to help you see if you are doing all you can to maintain a healthy back.

What are the most important things I can do for myself to maintain a healthy back? These are the top 5 steps you can take; each is described in more detail on the following pages: • Maintain good posture • Maintain good body mechanics • Reduce stress • Improve physical fitness • Improve flexibility

Maintain good posture Standing posture (Figure 9-1) • Stand with ear, shoulder, and hip in a straight line. • Keep shoulders relaxed, down, and back.

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• Shift weight from one foot to the other or put one foot on a low stool or shelf. • Avoid high heels, keep knees straight but not locked. • Use rubber mats, cushioned shoe inserts, and supportive rubber-soled shoes to help decrease strain on the legs and back.

Figure 9-1. Standing posture. Sitting posture (Figure 9-2) Sitting causes almost twice as much stress on the low back as standing. Sitting in a slumped position causes increased stress on the low back, upper back, and neck. Sit to support the back’s normal spinal curves: • Sit firmly against the back of the chair. • Keep head and shoulders back in line with hips. • Keep chair pulled in close when working at a desk or table. • Rest both feet on the floor or a low foot rest. • Keep a 90˚ angle at the hip, knee, and elbow. • Use armrests if available. • Get up and move around frequently. • Remember to use the same tips when driving!

Figure 9-2. Sitting posture.

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Sleeping posture (Figure 9-3) Maintain the normal curves of the back by sleeping on a mattress firm enough to support the natural curves of the back, but not extremely hard. • When lying on your back, use a rolled towel alone or with a thin pillow under your neck. You can use a pillow under your knees, too. • When lying on your side, use a folded towel at your waist if necessary. Pillows should be high enough to fill the width of your shoulder to keep your head in the midline of the body. A pillow between your knees may be comfortable.

Figure 9-3. Sleeping posture. Maintain good body mechanics Maintain the normal curves of the back when lifting, pushing, or pulling: • Bend with hips and knees (9-4A)—not the waist (Figure 9-4B)! • Keep weight close to the body when lifting (Figure 9-4C). • Tighten stomach muscles as you begin to lift. • Keep head and shoulders up when lifting (see Figure 9-4D). • Keep feet at least shoulder width apart and facing the object. • Pivot feet instead of twisting. Never twist and bend at the waist at the same time.

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• Use smooth, controlled movement—don’t jerk the load you are lifting. • Get help if you cannot move an object safely. • Push instead of pulling when possible. • Test the load before moving it. • Plan ahead: clear a path for the object to be placed. • Work together when two people are lifting an object.

Figure 9-4. A–D, Body mechanics.

On the job tips to help maintain good body mechanics: • Bending at the waist can increase back pain even when not lifting weight. • Workstations should be high enough so that no forward bending is required. A

• If counter or table level cannot be adjusted, change positions frequently. • Frequent or prolonged overhead work is stressful to the low back and neck. • Use a stool or step when possible and take frequent breaks to change positions. • Keep work as close to the body as possible—avoid repetitive forward reaching at arm’s length. • Allow enough space to move freely so that no twisting is required. Adequate space also allows for frequent changes in position. • Do not stay in any one position for prolonged periods of time. • Keep heavy, frequently used items stored between hip and shoulder level. • Avoid overhead lifting—store only light items overhead. Place items that are not used often on the floor. • Avoid staying in a flexed position—either slumped sitting or bending forward at the waist. B

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Reduce stress Emotional stress can contribute to back pain by causing back muscles to contract (which can cause back pain). There are several things you can do to help manage stress: • Learn to relax. For 15 minutes every day (or commit more time if you can) do yoga, meditation, breathing exercises, or anything you enjoy doing. Take time for you. • Recognize signs of stress. Do you become irritable? Do you have difficulty concentrating? Does your heart beat fast? • Learn your own signs of stress. Stop, look, listen, and rethink why a certain event is causing stress and what you can do about it. • Learn to let go. Accept the things you cannot change or control: traffic jams or a lazy coworker. Save energy for the

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things you can change—your attitude, taking time to relax, enjoying life. • Manage your time. Do things in order of importance and say “no” when you are doing too much. • Sleep at least 7 hours every night. • Exercise at least 5 times a week for 30 minutes.

Improve physical fitness People in poor physical shape are much more prone to back injuries. A healthy back can handle most stress and strain without being injured. • Know the difference between work and exercise. People may work at jobs that are very active, but still be in poor physical and flexible shape. They may also have strength only in certain muscles and weakness in others. • Recognize if your job requires a high level of strength, fitness, and flexibility. People often make no effort to keep their bodies in the physical shape needed to do these jobs.

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• Exercise. A regular exercise program will help you manage everyday stress and help relieve tension build-up. It will also help you condition your back muscles. Regular exercise • trains the muscles that protect the back, • conditions your whole body so that you can work for long periods of time, and • stimulates the body to produce hormones (endorphins) that improve your mood and help you relax. • Understand that regular exercise is the key to conditioning your back. Conditioning occurs by building up to 30 minutes of nonstop walking, stationary cycling, or swimming. These activities are called aerobic exercise (aerobic means “with oxygen”) because you breathe deeply, taking in more oxygen and increasing your heart rate. Be sure to “warm-up” to get your body ready for exercise, as well as “cool-down” to help your body ease-out of exercise.

Improve flexibility Loss of flexibility (the ability of muscles to stretch) is the single most important risk factor for developing back pain. The key to a healthy back is a balance between flexibility and back strength. Lack of strength in the abdominal (belly) muscles and lack of flexibility in the lower back, hamstring (back of the thigh), and hip muscles are the main causes of back problems. A daily program of stretching exercises shown on the next few pages will help stretch and strengthen muscles that are important for a healthy back. If you can, try to do all the exercises. Start slowly and don’t force any of the movements. It will take you about 15 minutes to complete all the exercises (Figures 9-5 to 9-11).

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Figure 9-5. Posterior pelvic tilt. Lying on your back, try to flatten your lower back into the floor by tightening your stomach and buttock muscles. Hold for 5 seconds.

Figure 9-6. Knee to chest. Lying on your back, keep one leg straight. Grasp the opposite leg behind the thigh and pull your knee toward your chest. At the same time, lift your head and shoulders up to meet your knees. Hold for 5 seconds. Switch legs and repeat.

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Figure 9-7. Trunk rotation. Lie on your back with both knees bent up. Rotate your knees from side to side as far as possible, keeping your shoulders flat. Hold on each side for 5 seconds.

Figure 9-8.

Hamstring stretch. A, Unilateral

stretch. Lie on your back as in Figure 9-6. Keep your hip at a 90˚ angle, and straighten your knee as far as possible. Hold for 5 seconds. Do opposite leg.

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Figure 9-8.

Hamstring stretch. B, Bilateral stretch. Sit with your feet flat against a wall and your knees flat on the floor. Keeping your arms at shoulder height, reach toward the wall. Hold for 5 seconds.

Figure 9-9. Curl-ups. Lie on your back with both knees bent up and cross your arms in front of your chest. Inhale (breath in). As you exhale (breath out), lift your head and shoulders up. Do two sets of 10.

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A

B

Figure 9-10. Press-ups. A, Lie on your stomach and place your hands flat on the floor at shoulder level. Press your body up with your arms and feet (curled toes). Keep your hips flat. Do two sets of 8. B, Do modified press-ups if press-ups are too difficult. Lie on your stomach and press up with your knees and arms. Keep your hips flat. Do two sets of 8.

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Figure 9-11. Standing back bends. Place your hands in the small of your back and bend backwards at the waist as far as possible. Look straight ahead; do not throw your head back. Hold for 5 seconds.

Back Care Checklist Do I do the following? • Keep my shoulders relaxed, down, and back when standing • Sit firmly against the back of a chair • Sleep on a firm mattress that supports my back • Bend with hips and knees, not the waist • Take frequent rest breaks when doing work that keeps me in one spot for prolonged periods of time • Relax 15 minutes every day by doing yoga, meditation, deep-breathing exercises, or just daydreaming • Exercise 30 minutes at least 5 times a week to the point where I perspire and my heart beats faster If you answered yes to all of the above questions, congratulations! You are already doing what is needed to maintain a healthy back.

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Glossary Acute means new or short-lived. Acute back pain is present for only a few days or weeks. Aerobic exercise is exercise that causes you to breathe deeply, taking in more oxygen and increasing your heart rate. Aneurysm is a stretching or ballooning of a blood vessel. Ankylosing spondylitis is a condition that usually affects young men and has a particular tendency to involve the sacroiliac joints. Antidepressant is a medication used to relieve depression. Arthritis is inflammation within a joint. Bone scan is a way to see bone injury, infection, inflammation, or cancer. Done by injecting radioactive material that will become concentrated in abnormal places in the bone. Chiropractor is a health care professional who can treat the spine with manipulation or “adjustments.” Chronic means long-lasting or ongoing. Back pain lasting over 12 weeks is considered chronic. Coccyx is the tailbone. Compression fracture is a flattening or “collapsing” of a vertebral body. This can occur with osteoporosis, injuries, or cancer. Computed tomography (CT) scan is a way to take cross-sectional pictures of the spine. Uses regular X-rays. Congenital means present at birth. Degeneration refers to disks that break down over time and become “dried out.”

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Disk (or intervertebral disk) is the cushion or shock absorber between two neighboring vertebrae. Diskography is a test for disk disease where material is injected into a disk. If pain results, that disk may be the cause of the patient’s pain. Electromyelography is a way to test nerves and muscles. Small needles are placed into the muscles and electronic signals are recorded. Facet joints are small, knuckle-like joints where vertebrae connect to one another. Flexibility is the ability of muscles to stretch. Herniation is a bulging or protrusion. Disk herniation can put pressure on nerves. Inflammation is swelling, redness, heat, and pain in reaction to an injury or other provocation. Insufficiency fracture is a usually unprovoked fracture associated with osteoporosis. Often involves the sacrum or the bones of the pelvis. Laminectomy is removal of some or all of the bony arch that covers the spinal cord in order to relieve pressure. Magnetic resonance imaging (MRI) is a way to take pictures of the spine and spinal cord. No radiation is used, instead, patients are placed within a harmless magnetic field. Multiple myeloma is cancer of the bone marrow. Often associated with a telltale blood protein abnormality. Myelography is a way to see the spine and spinal cord, which involves injection of dye into the fluid around the spinal cord. Regular x-ray films, or sometimes CT images, are then taken. Nonsteroidal antiinflammatory drugs (NSAIDS) are a class of drugs that will relieve pain, fever, and inflammation. Some are available over the counter. All can cause stomach irritation and involve other risks. Opioid is a narcotic drug such as codeine and morphine. All are potentially addictive (habit-forming).

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Osteopathic physician, also known as an osteopath or doctor of osteopathy (DO)., is a physician who offers manipulative or “hands on” spine treatments. Osteoporosis is often called “thin bones” and is a disease that causes a loss of bone density and strength. Osteoporosis occurs with aging but there are other causes. Paget’s disease is a bone disease in which the bone looks thicker than usual but is actually unhealthy and sometimes painful. “Red flags” are tip-offs in the history or examination that suggest serious problems. Sacroiliac joints are the joints between the sacrum and the sides of the pelvis. Sacrum is the large wedge-shaped bone at the lower end of the spine. Sciatica is pain that shoots or “radiates” down the leg caused by nerve irritation. Spinal canal is the channel in the spine, or spinal column, through which the spinal cord runs. Spinal cord is an important bundle of nervous pathways that begins at the brain and runs down the length of the spine. Spinal fusion is a surgical stabilization of the spine. Spinal stenosis is a narrowing of the spinal canal. This condition puts pressure on the spinal cord or nerves. Spine (or spinal column) is the backbone made up of disks and vertebrae. Spondylolisthesis is a slipping of one vertebra on its neighbor. Steroids are a type of drug that can reduce inflammation but can have serious side effects. Vertebrae are the drum-shaped bones that make up the spinal column. Each of them is called a vertebra and is made up of a solid “vertebral body” and some other bony attachments.

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