Banishing backaches

If your back aches, you’re not alone. In fact, the person who has never had back pain is the lucky exception. Back pain is ranked second only to headaches as the most frequent cause of pain. Four out of five adults will experience a bout of back pain at some time in their lives. It is also second only to the common cold as a symptom that sends people to their doctors. And all that care is expensive – not counting the cost of disability, which includes the millions of lost workdays each year. But although backaches are common, painful and expensive, they are rarely serious. Half the bouts of back pain resolve in less than a week, and three-quarters are gone in a month; only five to10 percent of these episodes turn into chronic pain.

If you’ve found a way to live with your back pain, don’t change a thing. There are almost as many theories and remedies as there are backs, and your system is likely to be as good as any other. Perhaps the best advice is to find the simplest, least disruptive, and least expensive approach that seems to work for you. But many people are not sure what they should do. Here are some answers to common questions.

What Causes Back Pain?

The explanations for back pain are legion. Muscle spasms and strains, bulging discs, pinched nerves, sciatica and arthritis are cited most often. Poor posture, tight muscles and abnormal alignment of the spine follow close behind. The list also includes osteoporosis, compression fractures, canal stenosis, tumors, vascular disease and disorders of the abdomen, pelvis, rectum, or hips that produce pain which is transmitted to the back.

It’s a long list, but the most common diagnosis is not on it: none of the above. The surprising truth is that the vast majority of episodes cannot be explained scientifically. True, a person with back pain may have arthritis, poor posture, or a bulging disc – but in most cases, his or her pain resolves even when the long-term abnormalities persist. Although doctors can’t be sure what causes garden-variety back pain, they can – and should – rule out specific problems that require specific therapy.

When Is Back Pain Serious?

This is the key question. Pain is always serious to the sufferer, but it doesn’t necessarily indicate a major medical problem. In general, severe or unrelenting pain is more worrisome than mild or intermittent discomfort, but many persons with severe low back pain recover, while a few with mild distress turn out to face serious problems. Whether your pain is severe or mild, you must be alert for warning signs that require medical evaluation and care. Following are some important warning signs:

• Onset of pain before age 20 or after 55

• Recent major trauma, including motor vehicle accidents, falls and severe sports injuries

• Radiation of pain down a leg, particularly if accompanied by: numbness or loss of sensation; weakness or loss of muscle strength; and impaired bowel or bladder control

• Pain that is constant and is not affected by motion

• Pain in the upper back or chest

• Pain that increases at night or when lying down

• Unexplained fever

• Unexplained weight loss of 10 pounds or more

• A previous diagnosis of cancer

You should see a physician without delay if your back pain is accompanied by one or more of these symptoms. But if you have uncomplicated low back pain, you have the option of trying to manage it first on your own before consulting a doctor since most episodes will resolve spontaneously without any management at all.

Should I Stay In Bed?

Bed rest has been a standard therapy for acute low back pain. Until recently, many people were treated with prolonged rest, sometimes accompanied by traction. But a 1995 study from Helsinki provides new guidelines: 67 patients with uncomplicated back pain were treated with bed rest; an equal number were instructed to maintain as many normal activities as their pain would allow. The groups were compared after three and 12 weeks. At both times, the patients who remained active had less residual pain and less disability.

Use common sense. Avoid heavy lifting, repetitive bending and twisting motions, and prolonged sitting. Be as active as your pain will allow, but don’t push too hard. You may not need strict bed rest, but you certainly won’t benefit from forcing yourself to be up and around in the face of pain. When you rest, lie on a firm surface such as a good mattress, with a bed board under it. If a heating pad makes you feel better, use it. If, on the other hand, an ice pack is soothing, use that. When you sit, select a chair with a good low back support. As you improve, spend less time resting, more time standing and walking.

Should I See A Chiropractor?

Chiropractors generally recommend spinal manipulation for back pain. Most physicians are skeptical but a few small studies suggest that manipulations may help speed recovery. Before you try chiropractic, be sure you don’t have any of the warning symptoms that should send you to a doctor instead. Remember, too, that most acute low back pain will resolve without manifestations and that physical therapy is an excellent means of achieving relief from pain that doesn’t resolve on its own. With these constraints, manipulation therapy is a reasonable option for those who feel their time and money will be rewarded with better pain control.

Should I See A Doctor?

If you feel warning symptoms, the answer is yes. For ordinary back pain, the choice is yours. It’s certainly reasonable to begin by taking care of yourself. But if your pain persists, for four to six weeks, you should see a doctor. For many cases, a primary physician is a good initial choice, with orthopedists, neurologists, rheumatologists and physiatrists (specialists in Physical Medicine and Rehabilitation) as reserves for more difficult cases.

If your discomfort is quite significant and your pain hangs on for four to six weeks, your doctor may include a series of x-rays along with a few simple lab tests, such as complete blood count (CBC), erythrocyte sedimentation rate (ESR) and urinalysis. More elaborate tests are rarely helpful for ordinary acute low back pain.

Should I Have A CT Scan Or An MRI?

Computed Tomography (CT scanning) is a powerful imaging technique that has revolutionized many aspects of medical care. For back pain, unfortunately, it’s been less valuable. In general, CTs should be used only when detailed imaging is necessary but MRIs cannot be performed. Magnetic resonance imaging (MRI) provides a superb look at the back, including the vertebral bones and joints, discs and the nerve roots. It’s noninvasive but it’s not suitable for people with pacemakers or certain metallic implants. MRIs are expensive and can trigger claustrophobia. Because they are time-consuming, they may be hard for people who cannot lie still because of pain.

MRIs have another drawback: they can be too sensitive. A recent investigation performed MRIs on 98 individuals who were entirely free of back pain. Only 36 percent of these people had entirely normal scans. More than half the people had at least one bulging disc, and more than a quarter had a more advanced disc protrusion. If these people complained of back pains, doctors would be tempted to blame it on disc disease, perhaps starting them on the path to invasive therapy.

Should I Wear A Brace?

Wearing a lumbosacral support (back brace, corset) for acute low back pain is another traditional treatment that had not been validated scientifically. In fact, there is some concern that a support may produce muscle weakness and stiffness. If you use a support, wear it only when you think it will do the most good, and be sure to keep your back flexible and strong with an exercise program when your pain has settled down.

What About Physical Therapy?

Although most acute low back pain will resolve with a simple, conservative, self-directed program, some people require additional treatment. Physical therapy treatments, usually under the supervision of the physiatrist, can be very helpful. Its mainstay is a low back exercise program and may include heat or cold treatments, ultrasound, traction, or transcutaneous electrical nerve stimulation (TENS). If physical therapy doesn’t help, doctors may treat selected patients by injecting steroids into the painful nerve roots.

And surgery is also available; it may be mandatory, even urgent, in certain cases of complicated back pain, but it should be the last resort for uncomplicated pain. If a herniated lumbar disc is responsible, a lumbar discectomy with magnified vision is usually preferred. Laser surgery and endoscopic procedures are being studied but are still experimental. Needless to say, different surgical approaches may be required to treat other problems.

How Can I Keep My Back Healthy?

A good mattress and supportive chairs are important. But the best way to prevent back pain is to keep the rest of your body healthy. Aerobic conditioning is paramount. Those who are active and fit have less back pain than sedentary people, who are more likely to be out of shape. Swimming, walking and biking are particularly desirable for people who have had back pains in the past. A good diet will also help – not by nourishing bones and joints but by preventing obesity. The old-time docs had it right when they said you can never be too thin for your back.

Because it’s so common, back pain is the subject of intense discussion among health care professionals and the general public. Everyone with a back, it seems, is an expert. Programs for prevention spark debate, theories about cause ignite controversy, and treatment plans start wars. Listen to the options and decide what’s best for you. For most people, a conservative, self-directed program will control acute low back pain. But whether you treat yourself or get professional help, you should always listen to your body, staying alert for the warning signs that could indicate serious trouble. Fortunately, such warnings are uncommon. For most people, basic care will banish backaches.