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Beating Back Pain

Low back pain is incredibly common, but that doesn't make it any less uncomfortable. This kind of pain can also be frustrating because it's often so difficult to pinpoint what's causing it. While it is frequently due to muscle strain or spasm, back pain may also result from nerve compression or, in some people, arthritis.

In order to ease the discomfort of low back pain, many people take to their beds. But experts say that although rest may feel like the right thing to do, for most cases of acute low back pain, it may, in fact, be counterproductive. And while people experiencing persistent and severe pain may require physical therapy and sometimes surgery, most people should try to stay as active as possible while the back heals itself.

Below, back pain researcher Dr. Steven Atlas, an assistant professor of medicine at Harvard Medical School and a primary care general internist at Massachusetts General Hospital, reviews common causes of back pain, as well as the steps one can take to cope with low back pain and prevent future episodes of it.

Why is low back pain so common?
One can view low back pain as part of life because most studies say that just about everyone will have it at some point in time. The issue of how debilitating it is, how long it lasts, and how often it occurs is what varies among individuals. There are lots of hypotheses about why low back pain is common. Basic biologists may talk about it in terms of pressure on the spine. Gravity puts a lot of pressure on the spine and specifically the lower spine, which is where most back pain occurs.

What are some risk factors for low back pain?
There's a lot of research that has looked at what increases the likelihood that you're going to have low back pain. But in general, there aren't huge studies that are of the highest quality.

But what you can say is that as people get older, they're more likely to have back pain. That's especially true for women, because of the onset of osteoporosis after menopause. Obesity is probably an important risk factor for developing back pain. There are known psychological factors such as depression and anxiety. And life stresses, whether they're personal or work-related, contribute to it. Some studies suggest that people who smoke cigarettes have a higher incidence of back problems. There's also evidence that people who are less physically active are more likely to have back problems.

From workplace studies, we know that people whose jobs that involve heavy lifting or vibration exposure, for instance, truck drivers, may be at higher risk for back pain.

Can low back pain always be traced back to an injury?
Clearly people can be involved in motor vehicle accidents, falls, injuries where the back is involved. But for most people who develop back pain, it's very hard for them to remember a specific event or injury that occurred.

What are some at-home recommendations to help with low back pain?
For people who have been having symptoms for maybe less than a week, there's some relatively simple things that can be done. Number one is not staying in bed. In the past, doctors put patients at bed rest for back pain. Now there's actually a lot of evidence that that isn't a really good idea. The concept of continuing with your usual activity as much as possible, particularly walking, is a very important thing.

A lot of people who have back pain due to the muscles and ligaments will often report that it's worse with prolonged sitting, so avoid that. If you spend a lot of time sitting at a desk at work, you need to get up and walk around.

The other thing that I often recommend is walking, because it is really good for most of the muscle and ligament problems associated with back pain. But there are studies that show that exercises that are good for strengthening the back, in the very acute stages, actually can make the pain worse.

Over-the-counter pain medicines such as acetaminophen and antiinflammatory medicines like ibuprofen, naproxen and aspirin, can all be effective ways of decreasing the amount of pain and letting you continue with your usual activities while the pain gets better.

Typically, in time, the body will heal itself.

When should someone seek out a doctor?
There are some studies that say only about 40 percent of people who have a back pain episode will go to see a healthcare provider. The most common reason to see someone would be for people who have back pain that is particularly severe and isn't letting them do their usual activities, or pain that isn't getting better after a number of days, or pain that radiates into the leg. If one thinks there's a pinched nerve, it's probably a good idea to be evaluated.

It is possible to distinguish between different causes?
It depends on where the pain is located. Sciatica refers to pain that originates in the back or buttocks and radiates typically down the back and side of the leg. Typically those people who have major pinching of the sciatic nerve will have the pain going down below the knee, usually all the way down to the ankle. Associated symptoms include numbness, tingling, and burning in the affected leg, and when severely pinched, the nerve injury can include weakness in the affected muscles.

For people who have pain that's limited to the back, there are a whole variety of causes, and it's very hard to come up with a definitive cause. There are studies that say that only about 15 percent of people who see a primary care doctor will be able to have a specific cause found. We think most of those sort of nonspecific causes are muscle and ligament related.

Young people who have serious pain usually have sciatica due to what's called a disk herniation, or a bulging disk. The disks are the pads between the spinal bones that cushion the bones and let your spine flex in different directions. There can be a tear in the ligament that keeps that disk in place; you can think of it like jelly from a jelly doughnut squirting out if there's a tear in the side. That disk material can irritate a nerve and can cause sciatica. In older patients, sciatica is usually due to arthritic changes in the spine-pinching nerves; this is called spinal stenosis.

There are other more serious things that cause low back pain that can be identified. Inflammatory arthritis, infections, fractures and cancer can all cause back pain, but they make up a minority of the huge number of people with back pain.

Many doctors and patients spend a lot of effort looking for these very uncommon causes. One of the goals of the evaluation is to quickly eliminate those things so that you can spend most of the time focusing on how to make it better and how to manage the pain.

What does the evaluation usually involve?
The most important thing is the history of the pain. How long has the back pain been going on? Where is it located? What makes it better, what makes it worse?

Then, I'll examine the patient. I'll look at some very simple things, such as how the patient walks across the room, how they transfer from standing to sitting, sitting to standing, how they get up on the exam table. I also look at how flexible their back is; if there is any pain when I push in certain spots; and if I can see signs of any muscle spasm. Depending on where their symptoms are, I'll check for signs of nerve irritation such as changes in sensation in the legs and in the feet.

For older patients with back pain, I'll make sure that the pulses in the feet are OK in case their back problems are being caused by problems with circulation.

I'll also ask people about what other symptoms they have. Sometimes back pain is associated with urinary infections and stomach problems. It's important to quickly make sure that there aren't any other symptoms going on that may lead to a primary source of pain other than the back.

When would you refer someone for imaging tests?
Sometimes, particularly if the pain hasn't been around for very long, an imaging test can actually give you the impression that there's more going on than there is. One of the problems with X-rays of the back is that if you do them in people who don't have any back pain, you often find all sorts of arthritic changes. So in people with back pain, there may be arthritic changes, but in fact, that isn't the cause of their pain; they just have a muscle spasm.

We consider imaging tests for the uncommon patients who have concerning findings that they either report or that the doctor sees on exam. The most common reason that one thinks about doing additional tests is that the pain isn't getting better. We'd also consider tests in someone who has back pain and a fever; someone who has marked tenderness when pushing on the bones of the back; someone who has a history of cancer; or someone who can't find a position that's comfortable.

If someone's acute pain isn't getting better, and they don't have any red flags, what treatment do you recommend?
The next step is for people whose symptoms aren't getting better over a week or two weeks, maybe three weeks. In general, that's when healthcare providers will often start talking about physical treatments such as physical therapy, chiropractic and massage. Usually someone will need treatments several times a week for several weeks.

But, patients need to understand that these treatments are geared toward getting you better quicker and are only marginally better than antiinflammatory medicines. So if there is some benefit it's not huge. It's not that, if you don't have them, you'll never get better.

What's the next line of treatment?
For many people who have very severe pain, particularly if it's affecting their sleep, doctors will give prescription pain medicines such as narcotics that are stronger pain relievers than over-the-counter antiinflammatory medicines. They will also give muscle relaxants.

I tend to avoid those medicines in patients with acute back pain that isn't so severe that they can't do anything, because they have more side effects than standard over-the-counter antiinflammatory medications.

For some people whose pain isn't getting better with conservative measures, one can think about injections of steroid medicines, epidural injections, that can get the pain under control while the body reabsorbs the disk. The body recognizes that the disc material is in the wrong plan. To remove it, the body mounts an inflammatory response that is very similar to what it does when it fight infections. These inflammatory cells result in the removal of the disc material. However, the same inflammation that helps fix the problem can make the symptoms worse in the short-term. That's why anti-inflammatory medicines can help control the pain.

But if the disk doesn't get reabsorbed, or if there's really severe pinching of the nerve, surgery may be appropriate.

What is the primary reason one would have surgery?
For patients with nonspecific back pain without leg symptoms, the role of surgery is controversial and usually viewed as a last resort. The most common reason that people with sciatica due to a herniated disk have surgery is that the pain isn't getting better with conservative measures. The most common timeframe is six weeks.

For people with arthritic changes due to spinal stenosis, because they tend to be older and surgery involves more risks, doctors often will give them a little bit longer with conservative measures. Often, the recommendation is to wait three, maybe six months to see if one can control the pain with physical-based treatments.

What does surgery involve?
For disk herniations, the surgery is often a very simple procedure where they just go in and remove the disk material that's gotten in the way of the nerve. It's often now done on an outpatient basis and the risks involved for otherwise healthy people is very small. So it's a simple treatment, but it's still surgery.

For people who have arthritic conditions due to spinal stenosis, the surgeries are more complex. In general, the surgery involves opening up the area where the arthritis is, in a procedure called a laminectomy. But more and more surgeons are doing more invasive procedures that involve fusion, which prevents the area where they think the pain is being caused from moving, using screws or other metal devices, in order to eliminate the pain.

What are good ways to prevent recurrence of low back pain?
For patients of mine who have acute pain, one of the important points that I make is that their pain is likely to get better with conservative measures. And that's the good news. The bad news is that, once you've had back pain, you're more likely to get it again in the future.

People need to do more to prevent future episodes. People have to get their weight under control, get more physically active, and do back-friendly cardiovascular exercises like walking, swimming, stationary biking.

For people who have very frequent episodes of back pain, back-specific exercises, both to increase the range of motion and strengthen the back, can be very helpful. But for most people, just general physical activity is a really good idea.