(Copyright Reader's Digest/Best Health. Originally published in Best Health, October 2010).
Everything you need to know about why your back hurts, and what you can - and can't - do about it
At some point, almost all of us - 80% of Canadians, most often between ages 30 and 50 - will have to deal with at least one agonizing bout of back pain.
That's because unlike most mammals, we walk upright on two feet, putting strain on our back muscles, bones and cartilage. Throw in high heels, heavy purses, pregnancy, a weekend warrior approach to exercise, and long hours in front of a computer or TV screen, and it's no wonder our bodies sometimes rebel at something as innocuous as lifting a child or swinging a hockey stick.
While faulty posture and inactive muscles can play a role in back pain, surprising new research also reveals a genetic component. The Twin Spine Study is a large, long-term study led by Michele Crites Battié, a professor of physical therapy at the University of Alberta who holds the Canada Research Chair in common spinal disorders. Published earlier this year in The Spine Journal, the study compared twins (half were identical pairs and half were fraternal) and found that even when each twin had very different exposures to activities thought to increase the risk of back problems, such as long-distance driving and frequent heavy lifting, they still had similar kinds of structural problems - called disc degeneration (Additional research has identified the specific genes involved.)
To complicate matters further: Much about back pain is not well understood even by medical experts; there are a huge number of potential treatments; and everyone seems to have a different opinion on what works. Dr. Scott Haldeman, a neurologist, chiropractor and clinical professor of neurology at the University of California, Irvine, dubbed this confusion "the supermarket approach." That is, trying to figure out how to treat your back pain is like going to a supermarket when you're hungry, and trying to buy just one thing. "A colleague and I looked at the research on back pain and found well over 200 different treatment options," says Haldeman. The two looked at treatments from world authorities and concluded: ‘buyer beware.' "Certain things do seem to have a high level of evidence to support them: exercise, some of the manual or manipulative therapies (physiotherapy and chiropracy], education on back care, anti-inflammatory medication and, in severe disorders, surgery. And that's it. Because everybody gets back pain, you have to find out what works for you."
Battié agrees. "There is no gold standard, no quick fix and little evidence that one treatment is clearly better than another," she says. "Patient preference should be a strong consideration."
So what should you do to soothe your aching back? Read on to learn about the steps you - with your health care provider - can take to help you feel better faster.
Ouch! WHAT CAUSES THE PAIN?
There are a lot of confusing back-ailment terms (Is a "bulging" disc the same as a "slipped" disc?) So it helps to understand a bit more about your back's anatomy. The spine, or backbone, consists of a stack of more than 30 round bones called vertebrae, which support the body and protect the spinal cord - a major column of nerve fibres that is connected to the brain, and runs through the vertebrae via the spinal canal. A disc, made of cartilage and filled with a gel-like material that acts like a shock absorber, is found between each vertebra. Ligaments, muscles, tendons and small joints, called facets, hold the vertebrae together.
DISC PAIN If one of the discs is pushed a bit out of place, usually as a normal part of aging, it's called a "bulging" disc. If this disc has some cracked cartilage - due to an inherited trait, wear-and-tear or sudden trauma - and some of the shock-absorbing gel inside the cartilage protrudes out, it's called a "herniated," "ruptured" or "slipped disc." Both bulging and herniated discs may or may not cause pain. "Degenerative disc disease" is not in fact a disease, but rather a kind of catch-all term that refers to the condition of the discs, which lose their water content and sponginess as we age, which can lead to osteoarthritis, bulging discs or herniated discs.
FACET JOINT PAIN Facet joints are supplied by two nerves, and if either becomes inflamed or pinched, it can be painful.
PINCHED NERVE Or the out-of-place discs may compress a nerve. Often it's the sciatic nerve, which runs out of the lower spine and into the leg, that is compressed or inflamed, causing shooting pain in the lower back, leg and buttock called sciatica.
SPINAL STENOSIS This occurs when the spinal canal becomes narrowed, most often due to arthritis, and impinges on nerves, causing pain.
OTHER SOURCES
MUSCLE OR LIGAMENT STRAIN An intense workout or lifting something heavy is also a frequent source of pain, especially in the lower back. Low back pain is the most common form of back pain because those muscles, ligaments and discs are under the most pressure when you're sitting or lifting.
OSTEOARTHRITIS This common form of arthritis is another source of back pain. "As we age, our nice spongy cartilage gets thinner and is not as compressible," explains Dr Mary-Ann Fitzcharles, a Montreal rheumatologist and associate professor of medicine at McGill University. "The underlying bone senses this and responds by putting little extra ridges of bone called osteophytes or bone spurs. These little ridges rub against each other and this mechanical irritation can cause pain."
FIBROMYALGIA, which mainly affects women, is also a rheumatological disease linked to back pain. "Many patients will experience back pain, but it's not because of a structural abnormality," Fitzcharles says. "Rather, the impairment of the pain processing mechanisms means the brain is hypersensitive to incoming sensory input or there is a lack of natural mechanisms to inhibit pain."
WARNING SIGN Back pain is occasionally a symptom of a serious condition. If you have a history of cancer, or if your back pain is associated with fever, unexplained weight loss, loss of bowel or bladder control, or gets severely worse when lying down or at night, see a health care professional immediately.
While the source of your pain could be from any one of these common issues, it's possible, even likely, that you may never know the exact problem. "In about 85 percent of back pain, we don't have a specific underlying pathology that can be identified as the cause," notes Battié.
WHAT CAN YOU DO?
You bend down to pick up a pen, or lunge for the puck, and are suddenly gripped with back pain. What do you do? Most back pain responds to a similar approach to treatment .
REST UP According to current clinical practice guidelines, you can rest for a day or two while the pain is acute, using pillows to keep you in a more comfortable position.
DO COLD THEN HOT Use a cold pack to reduce inflammation in the first few days, then switch to a heating pad or hot water bottle to help relax tense muscles and improve blood flow to the area.
GET EXPERT ADVICE Talk to your doctor about a referral to a physiotherapist or chiropractor. Either can be helpful, both for suggestions about back-friendly stretches and activities, as well as physically evaluating and manipulating your back. (Of course, avoid actions that really exacerbate your pain - now is not the time to move the piano.) Massage or acupuncture treatments may also help loosen tight muscles and soothe painful spasms.
START MOVING Resume your normal activities as best you can. After a couple of weeks include gentle exercise such as stretching, walking, yoga or swimming.
WORK OUT WITH WEIGHTS Experts stress that choosing activities that you enjoy and will stick with is crucial. But some activities do appear to be more beneficial than others. People with chronic low-back pain who did a supervised 16-week program of resistance training with weights had greater reduction in pain and disability and reported an improved quality of life compared to those who did aerobic training for the same period of time, according to a small 2009 study from the University of Alberta and the University of Regina, published in the Journal of Strength and Conditioning. The reason why exercise helps back pain is somewhat of a mystery. It's thought that increasing muscle strength to help support the back, keeping ligaments limber, losing excess weight and, perhaps most importantly, improving psychological well-being - lessening fear and fretting about pain and disability - are all key elements of why exercise works.
DRUGS - IF YOU NEED THEMTake the recommended dose of over-the-counter pain medication like acetaminophen (such as Tylenol) or NSAIDs such as ibuprofen (Advil). (Doctors caution against long-term use of NSAIDs because of the risk of gastrointestinal problems, including ulcers.) A prescription muscle relaxant, such as cyclobenzaprine, can be taken for a week or two at most.
THE BEST HEALER
"The effects of any of these treatments are modest, but they will probably help you get to a positive outcome a little more quickly," says Battié. "Nature is still the best healer." Battié herself experienced a six-week bout of severe back pain, shortly after giving birth (see Pregnancy pain sidebar). "Knowing that back pain is seldom long term really made a big difference, so it wasn't a frightening experience for me. It was frustrating and inconvenient, but I knew it had to just run its course."
Sidebar: Is surgery for you?
A small minority of back pain patients (less than 10 percent) may require surgery to address long-term pain. "While it's true that back pain goes away on its own in the vast majority of cases, surgery is useful because it gets people better faster." says Dr Michael Ford, a Toronto orthopedic surgeon and past president of the Canadian Spine Society. He adds, though, that for surgery to succeed, the surgeon has to clearly identify the source of the pain, and that's often very difficult to pinpoint.
The three most common surgeries are microdiscectomy (where part of a disc is removed to reduce pressure on nerves), a laminonotomy or laminectomy (where the spinal canal is enlarged to reduce pressure on nerves) and fusion (where two vertebrae that are unstable due to fracture or disc degeneration are permanently fused together). These surgeries are often done with minimally invasive, microscopic techniques, so otherwise healthy patients can go home the same day or after a couple days in the hospital, says Ford.
Sidebar: Pregnancy pain
Pregnancy packs a triple-whammy: Increased weight, decreased activity and loosened ligaments due to changing hormone levels all contribute to back pain, both before and after the baby is born. According to a study published in BMC Pregnancy and Childbirth in 2008, women who managed their pain by working with a physical therapist to set goals and choose which exercises to do recovered faster than women who either did nothing, or were told what exercises to do by a physical therapist.
