At one time or another, the misery of lower back pain is felt by everyone, which is no surprise. Our upright spine is as unique to being human as having an opposable thumb. But where anyone can see that using our hands involves every aspect of life, we don't say the same about our backs. But it's just as true. You can read a great deal standing behind someone, reading victory or defeat, success and failure, pride or shame and every degree of self-esteem. More hidden are the stresses that shape the back. On the day that you feel that first twinge of back pain, an entire personal history has already unfolded.
Can we use that history to treat lower back pain?
The factors to consider are as varied as each person is, but the most salient include:
- Physical stress to the lower back
- Sedentary jobs
- Lack of exercise
- Untended psychological issues
- Depression, anxiety
- Sudden changes in physical routine
- Bad sleep
- Coping mechanisms, how you deal with stress
- Old traumas, such as car accidents and sports injuries
- Unknown predispositions
That's a lot to consider. As you can see, saying "My back went out" or "I must have hurt my back" falls short of an adequate explanation. Everything on the list needs to be considered as a contributing factor. It's important to distinguish between acute pain and chronic pain. Acute pain is intense and lasts from a few days to several weeks. Acute back pain is generally due to sprains or strains and usually gets better in a few weeks. Chronic pain lasts longer than three months. Chronic back pain is more complicated in terms of its causes and its treatment.
We can start with a very general picture. Medicine knows a lot already about this chronic problem. About 1 in 6 Americans suffered from back pain continually for every day of the last month; a quarter of the population reports that they have had back pain in the last three months. Back pain is the No. 2 reason people visit their doctor (No. 1 one is colds and flu).
And back pain is on the rise. The percentage of people getting care for spine problems increased from 10.8 percent of the U.S. population in 1997 to 13.5 percent in 2006. The health care costs of back pain are up, too -- way up. Expenditures for opioid medications for spinal problems increased an incredible 660 percent during that same period of time, and health expenditures for spine problems rose from about $19 billion to $35 billion, an increase of 82 percent.
These dramatic increases go hand-in-hand with the rise in back pain surgery. Almost one million spinal surgeries are performed in the U.S. each year. About one-fourth of them are spinal fusions, costing an average of $60,000 each. Most of these surgeries, besides being notoriously unpredictable in their success rate, are unnecessary, and a great many of the unsuccessful ones require re-operation. Surgery often leaves patients in pain, unable to return to work and dependent on opiate medications. We need to realize, on the positive side, that most back pain will respond to conservative treatment that leaves the patient able to return to work and free of the need for opiates.
The complex architecture of the human spine makes us susceptible to accidental sprains and strains of the back muscles and ligaments. These passing incidents are by far the most common cause of lower back pain. Sprains occur when ligaments are overstretched or torn from their attachments. Strains happen when muscles are ripped or torn. The injury generally happens when you fall, lift something improperly, carry a heavy object or make a sudden movement. Just having poor posture can cause sprains and strains, too. Other, nonspinal causes of back pain include fibromyalgia and depression (often accompanied by anxiety). Fibromyalgia is thought to be an inflammation of the connective tissue (including the muscles) of the body. Depression and anxiety often manifest with physical symptoms.
The good news is that most of the factors that put you at risk for back pain can be changed or modified: Look carefully at stress, depression and anxiety, heavy backpacks, poor posture, being overweight, not getting enough exercise, smoking, unhealthy diet, certain medications and job hazards. Risk factors you can't do as much about may include aging, family history of back pain and having had a previous back injury. Still, there are people with healthy backs who have such risk factors but overcome them.
In about 85 percent of back pain patients, no clear cause is ever identified. In order to diagnose back pain, a number of imaging technologies are now regularly employed -- X-rays, CT scans and MRI scans are the most common. But it is still very difficult to find out why someone is experiencing chronic back pain. Quite frequently, imaging tests reveal abnormalities of the spine, such as spondylolisthesis and herniated discs, and it's tempting to immediately ascribe back pain to these abnormalities. But bear in mind that these conditions are often found in people who have no symptoms of back pain at all. These abnormalities might have absolutely nothing to do with the pain you feel.
The majority of back pain heals without any significant medical intervention. Only a very small minority of back conditions require surgery. Worse still, about one-third of spinal surgeries fail to relieve back pain, often requiring reoperation. This happens so often there's even an acronym for it: failed back surgery syndrome (FBSS).
Fusion surgery is an increasingly popular type of back operation in which two or more vertebrae are fused together. Fusion surgery may be useful for slipped vertebrae or some types of fractures, but it is often prescribed for herniated discs, degenerated discs or nerve problems. One large-scale study of almost 1,500 people with back pain found that after two years, only one-fourth of people who had fusion surgery had returned to work, while two-thirds of people who hadn't had the surgery were back on the job. There was also a 41 percent increase in the use of opiate painkillers by the surgery patients compared with those who hadn't had surgery.
Other studies have found that people who have fusion surgery for degenerative disc disease have worse outcomes than people with the same condition who choose not to have surgery. In spite of these startling numbers, fusion surgery for degenerated discs is the fastest-growing type of spinal operation. Spinal surgery should be reserved for cases where spinal nerves are compressed and are causing the loss of bladder or bowel control, or creating weakness or numbness in the legs. Only under these conditions, or when someone has chronic, debilitating back pain and has given all conservative, nonsurgical methods a fair trial, is it time to consider back surgery.
There are many nonsurgical measures for treating back pain, and they are generally most effective if used in combination with one another. If you have acute back pain, the first line of defense is "fire and ice" -- hot pads and cold packs for easing pain and inflammation. After a few days of rest, you should start to become more physically active and gradually begin to do gentle exercise. Consult with a physical therapist to determine when you're ready for stretching and strengthening exercises. NSAID medications or spinal injections of steroids or anesthetics can provide enough pain relief to allow physical therapy. Massage helps stimulate circulation to the back tissues and aids flexibility. Chronic back pain may be helped by psychological therapy as well.
Alternative therapies can be helpful. Many people swear by acupuncture and chiropractic manipulation. Trigger-point therapy treats muscle pain by injecting anesthetics or steroids into painful areas of muscle. If you want to prevent lower back pain, the single most important measure you can take is to stretch and strengthen your core muscles through regular exercise. Yoga and Pilates are ideal for this. Aerobic exercise is helpful because it strengthens your cardiovascular system, increasing circulation to the tissues of your back. Be aware of your posture: Avoid slouching, which places a great deal of strain on your back.
Being overweight strains your back as well, so lose weight if you need to. If you smoke, quit -- smoking literally starves your vertebral discs of oxygen and nutrition. Eat high-nutrition, whole foods to keep your bones and back tissues healthy. Finally, find ways to relax if you're stressed out, because tension alone can create back pain.
We have a national disposition to rely on drugs and surgery that is not abating. Our lifestyles are not going to become less sedentary; our lack of exercise and reluctance to treat stress are endemic. So lower back pain waits in the wings to test if each of us can take advantage of the knowledge that exists about this problem, and then to turn it into practice in our only day-to-day habits.