Low back pain
Dr A Alphine Caroline Jenitha
Low back pain Guide
Low back pain is one of the top reasons that Americans see their doctor. Most Americans, moreover, experience back pain at one time during their life. Many back related injuries happen at work. But, you can change that. There are many things you can do to lower your chances of getting back pain.
What is low back pain?
If you are like most people, you will have at least one backache in your life. While such pain or discomfort may be felt anywhere in your back, the most common area affected is your low back. This is because the low back supports most of your body's weight
You may feel a variety of symptoms. You may have a tingling or burning sensation, a dull aching, or sharp pain. You also may experience weakness in your legs or feet.
It won't necessarily be one event that actually causes your pain. You may have been doing many things improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.
How long will the pain last?
Low back pain is usually defined as either acute (short-term) or chronic (long-term, continuous, ongoing). Having acute back pain more than once is common, but continuous long-term pain is not.
• Acute low back pain lasts less than 1 month and is not caused by any serious medical condition. Most cases get better within 1 week, even without medical attention. It is common to have another episode of pain at a later date, after the first attack. There are many steps you can take to prevent this recurrence.
• Chronic low back pain lasts for more 3 months.
As you will learn later in this guide, there are definite steps that you can take to avoid both continuous, chronic pain and acute pain that comes and goes.
Know your back anatomy
Before we discuss the causes of back pain, it will help you to understand the bones, nerves, and muscles in and around your spine. An abnormal function of the vertebrae, disks, ligaments, muscles, and nerves coming out of the spine may cause pain.
The spine is a column of small bones, called vertebrae, that run along the center of your back. The vertebrae support your trunk and upper body and protect the nerves that connect the brain to the rest of your body. This. bundle of nerves is called the spinal cord. The spinal column is grouped into different sections:
• Cervical spine: these 7 vertebrae support the neck.
• Thoracic spine: these 12 vertebrae are attached to the ribs in the chest.
• Lumbar spine: these 5 vertebrae are the lowest and largest bones of the spinal column.
• The sacrum, a shield-shaped bone, connects your back to your pelvis.
• The coccyx (tailbone) is at the end. It consists of tiny vertebrae fused together.
• The lumbar vertebrae bear more of your body's weight and stress than any other part of your back. Therefore, this region (the lower back) is the most likely to get injured.
• Each vertebra is referred to by a particular letter and number. The letter is the region (C=cervical, T=thoracic, and L=lumbar), and the number is the spot within that region. For example, C4 is the fourth bone down in the cervical region, and T8 is the eighth thoracic vertebra.
• If you reach around and feel along your spine, you would be touching bony projections along the back of the vertebrae. These are called spinal processes. Your doctor counts these (C1-C7, T1-T12, and L1-L5) to tell from where your pain and injury may be coming. Imaging tests, like an MRI, may be used to pinpoint the location and cause with more certainty.
• For example, you may hear your doctor say after the exam that "your pain is between L3 and L5." After an MRI, the doctor may indicate the precise location and nature of the problem. For example, "you have a herniated disk between L4 and L5."
• Between each vertebra is a disk that cushions and protects it. The outside of the disk, called the annulus fibrosus, is largely made of cartilage. The inside of the disk, called the nucleus pulposus, is a jelly-like substance that contains a lot of water.
• The vertebrae and disks of the back are surrounded by numerous muscles (called paraspinous muscles) and ligaments. These provide strength and support for movement, including lifting and bending. They are often referred to as soft-tissues because they are not hard, like bone.
• Stomach and chest muscles also support your back. When these muscles are strong and well-conditioned, they help reduce the stress on your lower back by redistributing weight.
• Most people fear that they have hurt their spine or disk when they experience back pain. That is much less common, however, than straining your paraspinous muscles or other surrounding soft-tissue.
The spine is surrounded by a surprising number of muscles and ligaments at different levels. These give the spine great strength. Click each button above to see different layers of muscles, tendons, ligaments, and bones of the back
Causes of low back pain
Back pain is frequently associated with muscle strain or spine problems. However there are many other medical reasons that cause back pain, and most patients do not have a clear history of trauma or medical strain. Sometimes it may be the result of an illness.
You may first feel back pain just after you lift a heavy object, move in a sudden, abrupt manner, or suffer an injury (for example, a fall or a car accident).
However, the specific cause of back pain is often never identified. This can be good news, because when the specific cause is easily determined, the problem may be more serious.
Whether identified or not, there are several possible sources of low back pain. The most common are:
• Muscle strain
• Ruptured or herniated disk
• Degeneration of the disks, such as osteoarthritis
• Muscle spasm (very tense muscles that remain contracted)
Other causes include:
• Spinal stenosis (narrowing of the spinal canal)
• Tears to the muscles or ligaments supporting the back
• Small fractures to the spine from osteoporosis
• Other systemic (body-wide) medical conditions. In these cases, back pain is often associated with other symptoms such as prolonged morning stiffness.
Disk degeneration, herniation, and rupture
As you get older, the disks in the spaces between the vertebrae can deteriorate (weaken). This process is similar to arthritis in other joints in the body. The weakening from general wear and tear leads to irritation and inflammation, both of which can cause pain.
If the disk degenerates enough, the area becomes very thin and the jelly-like substance (nucleus pulposus) within the disk can bulge outward. This is called herniation.
There are different degrees of herniation. Many people have slight bulging that causes no symptoms at all. Others have an extensive bulge (called an extrusion), which may cause pain. Even extrusions, however, do not cause pain in everyone. This varies greatly from person to person.
A ruptured disk is a sudden herniation that happens from a serious injury. When a disk herniates for this reason, it is not necessarily related to the wear and tear of age.
Muscle strains and ligament injuries
Muscles and ligaments are important structures that support and strengthen your back. They are located all along the spine, including thick bands surrounding the disk spaces. A strain or actual tear to any one of these muscles or ligaments can cause back pain. Two common areas of such injuries include the thick fibrous band along the side of each disk and the ligaments that connect the spine to the pelvis.
Spinal stenosis is narrowing of the spinal canal, or narrowing of the openings (called neural foramina) where spinal nerves leave the spinal column. This can develop as you age. If you have stenosis, even a minor injury can cause inflammation of the disk and pressure on a nerve. You can feel pain anywhere along your back or leg that this nerve goes to.
Often, you will have pain in the buttock, thigh, or leg that is brought on by activity and relieved by rest. The pain is also relieved by a stooped posture, so that you can walk farther while bending over than standing straight. Pain of this type is virtually specific for spinal stenosis, which is more common in older individuals. This specific problem is also called neurogenic claudication.
There are lots of other potential causes of back pain, many of them rare. Some other possible causes are:
• Misalignment of the vertebrae -- for example, one vertebra may slip forward
• Wearing down of the spine bones (as opposed to the disks) of the vertebrae
• Inherited spine abnormalities
Are you at risk?
Many things can make you more likely to develop back pain. Such risk factors include:
• Age. After age 30, the disks between your vertebrae begin to deteriorate and grow thinner, which puts you at greater risk for disk herniation. The disks also lose water, which puts you at risk for spinal stenosis.
• Genes. You may inherit certain structural abnormalities in your spine or a have a genetic predisposition for back problems (for example, many people in your family may have problems with back pain after a certain age).
• Lower pain threshold. Lots of people have spine problems, like bulging disks. But not everyone experiences pain from them.
• Arthritis. The kind of arthritis that happens with age, called osteoarthritis, can often affect the joints of the lower spine. Another common kind of arthritis, called rheumatoid arthritis, can affect vertebrae, but usually in the neck, rarely the lower back.
• Depression, stress, and unhappiness at home or work. These all make you more likely to experience back pain. Depression also makes it more likely for your back pain to become a long-term, ongoing problem. Depression and stress may lower your pain threshold.
• Pregnancy. The changes that happen in your body when you are pregnant make you very susceptible to back pain. First, your weight redistributes. Also, the ligaments in your pelvis purposefully loosen to get your body ready to deliver a baby. Having a loose pelvis can last for weeks to months following the delivery.
• Osteoporosis. A decrease in bone density (called osteoporosis) happens as you age, especially in women after menopause. As you lose bone density, the bone weakens and fractures become more likely. Tiny fractures in the vertebrae from osteoporosis can cause back pain. Another possible outcome from loss of bone strength is sudden collapse of a vertebra. This may be very painful.
• Certain occupations. Jobs that involve heavy lifting, forceful movements, lots of bending or twisting, and whole body vibration (for example, long-distance truck driving) place you at greater risk for low back pain.
• Lack of exercise. If you do not exercise regularly, you are more likely to develop low back pain. This is especially true if you suddenly attempt an activity that you haven't done in a long time. Shoveling snow and moving furniture are common examples.
• Being overweight. Carrying around extra pounds puts additional stress on your spine.
• Smoking. Cigarettes may put you at increased risk for back problems. This may be because tobacco causes poor blood circulation. Or it may be because when you smoke, you are more likely to have other bad habits, like not exercising.
What to do when pain begins
Many people will feel better within 1 week after the start of back pain. After another 4 - 6 weeks, the back pain will likely be completely gone. However, it is important to take the right steps when you first get pain. This can help make sure that you are one of the many people who get better right away.
No matter how often you get back pain, follow these steps every time you feel pain.
It is a common misconception that you need to rest and avoid activity for a long time after you hurt your back. In fact, bed rest is NOT recommended. If you have no indication of a serious underlying cause for your back pain, then you should stay as active as possible. Otherwise, you should reduce physical activity only for the first couple of days and gradually resume your usual activities after that. Here are some tips for how to handle pain and activity early on:
• Stop normal physical activity for the first few days. This helps calm your symptoms and reduce any inflammation in the area of the pain.
• Apply heat or ice to the painful area, whichever feels better to you. Another good method is to use ice for the first 48 - 72 hours to reduce inflammation, followed by using heat to help loosen the muscles.
• Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin) or acetaminophen (Tylenol). If you cannot take either of these for medical reasons, like a stomach ulcer, stomach inflammation, or a liver disorder, then check with your doctor for other pain relieving measures. Selective anti-inflammatory medicines called COX-2 inhibitors may be less harmful to the stomach, but serious questions have been raised regarding their effects on the heart.
• Muscle relaxants are not first-line therapeutic agents, but may be considered when there is significant muscle spasm. Such drugs cause drowsiness, and should be taken at bedtime.
• Getting a good night's sleep when you have back pain can be quite difficult. Try taking a warm bath or practicing relaxation techniques before going to bed. Also, lie in a curled-up, fetal position with a pillow between your legs. If you usually sleep on your back, place a pillow under your knees to relieve pressure. A firm, but comfortable, mattress is recommended.
What NOT to do
• Do NOT confine yourself to bed. Over time, bed rest can lead to loss of muscle tone and bone strength. This can cause depression, drain your energy level, and put you at risk for blood clots.
• Do NOT perform activities that involve heavy lifting or twisting of your back. Avoid exercise in the days immediately after the pain begins. You should gradually resume physical activity as soon as possible, particularly under the guidance of a physical therapist.
See your doctor
You should see a doctor the first time you have back pain, so that you can get a full examination. Your doctor will be looking to see if the pain is caused by a serious condition.
If you have any of the following symptoms, be sure to contact your doctor immediately:
• Severe pain that is not resolving with conservative measures
• Numbness, tingling, weakness or loss of sensation of your legs
• Loss of bowel or bladder control
Seeing your doctor
When you first see your doctor, you will be asked questions about your back pain, including how it started, how often it occurs, how severe it is, and what makes it better or worse. Your doctor will try to determine the cause of your back pain and whether it is likely to quickly get better with simple measures such as ice, mild painkillers, physical therapy, and proper exercises. Most of the time, back pain will get better using these approaches.
During the exam, your doctor will try to pinpoint the location of the pain and figure out how it affects your movement. You will be asked to:
• Sit, stand, and walk. While walking, your doctor may ask you to try walking on your toes and then your heels.
• Bend forward, backward, and sideways.
• Lift your legs straight up while lying down. If the pain is worse when you do this, you may have sciatica, especially if you also feel pain, numbness, or tingling in one of your legs.
Your doctor will also move your legs in different positions, including bending and straightening your knees. All the while, the doctor is assessing your strength as well as your ability to move.
To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many locations with a pin, cotton swab, or feather tests your sensory nervous system (how well can you sense or feel touch). Your doctor will instruct you to speak up if there are areas where the sensation from the pin, cotton, or feather is duller.
Most people with back pain recover within 4 - 6 weeks. Therefore, your doctor will probably not order any tests during the first visit. However, if you have any of the symptoms or circumstances below, your doctor may order imaging tests even at this initial exam:
• Pain that has lasted longer than one month
• Muscle weakness
• Accident or injury
• If you are over 65
• You have had cancer or have a strong family history of cancer
• Weight loss
In these cases, the doctor is looking for a tumor, infection, fracture, or serious nerve disorder. The symptoms above are clues that one of these conditions may be present.
If you are following your doctor's initial instructions and do not improve after 1 - 3 weeks, you should call for a followup appointment. Your doctor will determine if you need to see a physical therapist and can refer you to one in your area.
If your pain lasts longer than one month, your primary care doctor may order imaging tests and send you to see either an orthopedist (bone specialist) or neurologist (nerve specialist).
What tests might be ordered?
Your doctor can use a number of helpful imaging studies to examine the structures of your back, including your spine, if needed. Other tests assess the electrical activity of your muscles and nerves. These tests are used to try to identify the exact location and source of your pain.
An x-ray of your back may show a sign of an injury, infection, fracture, osteopenia (loss of bone density), or tumor. However, most people with low back pain due to strain or spinal problems have normal x-rays. If the results of an x-ray are not definitive, your doctor may order a CT or MRI scan.
CT and MRI scans
Computed tomography (CT) and magnetic resonance imaging (MRI) can be used to identify disk abnormalities and any other problems in the back. MRIs are more accurate for soft tissue, but CTs are better for bones and small joints. MRIs provide very clear pictures of all parts of the back, including muscles, ligaments, and the vertebrae. These tests can also identify infections and tumors if present.
Your doctor may order a lumbar MRI if you have signs or symptoms of:
• Low back or leg pain that is severe or does not get better after treatment by your doctor
• Low back pain and weakness, numbness, or other unusual findings on physical exam
• Fever or other signs of infection
• Injury or trauma to the lower spine
• Problems with bowel or bladder function
Nerve and muscle studies
• Based on your description of back pain, your physical exam, or any imaging studies performed, your doctor may order studies to test the activity of your back muscles and spinal nerves. Nerve conduction studies are done more often than muscle testing. (Muscle testing can be quite painful.) Nerve conduction tests involve placing electrodes on your skin and applying small electrical signals. With these shocks, the speed with which your nerves conduct the signal is measured.
• Other tests
• Blood and urine samples may be used to test for infection, arthritis, or other conditions.
When is low back pain a serious sign?
Tests will be ordered if your doctor has concerns that a serious problem or underlying medical condition is causing your back pain. Keep in mind that most of the time, low back pain gets better on its own with little intervention or only simple treatment measures.
Cauda Equina Syndrome
In the lowest part of the spinal column, there is a collection of nerve fibers, sometimes called "the tail" of the spinal cord. This collection of nerves is called the cauda equina, Latin for horse’s tail. If these fibers become trapped, you can lose control of bladder and bowel function. This is called cauda equina syndrome. Other symptoms of this condition are:
• Dull back pain
• Weakness or numbness in your buttocks, genital area, or thighs
• Inability to control urination or bowel movements
This condition must be treated with immediate surgery to reduce the risk of permanent problems.
Other warning signals
When evaluating you for back pain, your doctor will be checking for signs of the following:
• Infection (like meningitis, an abscess, or urinary tract infection)
• Kidney stone or other kidney disorder
• In men, a problem with the testicles or scrotum (like a twisted testicle)
If any of the following are present, it will raise greater concern that one of these problems may be causing your back pain:
• Pain awakens you at night.
• You have a fever along with your pain.
• Pain gets worse when you lie down.
• The pain is not related to your movement. In other words, no particular movement makes the pain better or worse. It is just bad all of the time.
• You have been losing weight unintentionally around the time that your pain began.
• You have a long history of steroid use (for example, for severe asthma).
• You use intravenous drugs.
• You have urinary tract symptoms along with the back pain like burning with urination or blood in your urine.
• Your pain is very sharp.
Exercise and physical therapy
Exercise and physical therapy can help in many ways. If you see a physical therapist and learn to exercise properly, you will recover faster and your back pain is less likely to happen again. Physical therapy and exercise help you accomplish these important goals by:
• Teaching you better posture
• Making your back stronger and more flexible
• Getting you back to work sooner
• Making it easier for you to resume normal home and social activities
• Assisting you in losing weight
• Showing you how to avoid falls (especially important for those with a narrow spinal column, called spinal stenosis)
• Helping you feel better about yourself
What type of exercise is best?
Stretching and strengthening exercises are important in the long run. However, starting with these types of exercises too early can make your pain worse. For this reason, it is usually best to begin with light cardiovascular training. Walking, riding a stationary bicycle, and swimming are great examples that you can start as soon as two weeks after your symptoms began. Such aerobic activity can help blood flow to your back and promote healing. They also strengthen muscles in your stomach and back.
Working with a physical therapist is very useful to guide your recovery. The physical therapist will help you determine when it is safe to do these different types of exercise.
Exercise that you shouldn't do
Avoid these exercises during initial recovery unless specifically instructed by your doctor or physical therapist:
• Contact sports
• Racquet sports
• Weight lifting
• Leg lifts when lying on your stomach
• Sit-ups with straight legs (rather than bent knees)
What will the physical therapist do?
At first, the physical therapist will try to reduce your pain and inflammation by using methods like:
• Gentle stretching and manipulation
• Electrical stimulation
When the therapist performs ultrasound, a probe with jelly is rubbed over your skin in the area of your pain. Sound waves are transmitted through the probe. The sound waves penetrate to your tense muscles to help them relax.
For electrical stimulation, the therapist places electrodes around the area of your pain. Tiny pulses of electricity are sent through the electrodes. Like the sound waves from ultrasound, the pulses of electricity enter your painful, tense muscles, helping them relax and feel better. By raising the intensity (strength) of the electricity very slowly, the therapist has you direct how much of the pulsations you can take. It doesn't hurt because you tell the therapist to stop before it feels painful or to back down when it feels slightly uncomfortable.
The physical therapist will also teach you how to move correctly in order to avoid twisting, bending, and lifting improperly. When your back is strong enough, you will be taught stretching and strengthening exercises to avoid getting back pain again.
Change your work habits
The ways that you move, stand, and sit affect your back.
• Maintaining good posture is very important. This means keep your ears, shoulders, and hips in a straight line. You should use your eyes to look straight ahead, which will keep the head and neck in the right position. The stomach should be relaxed. This is important when you are sitting as well.
• Don't stand for long periods of time. If you must for your work, try using a low stool. Alternate resting each foot on it.
If your work requires you to walk a lot:
• Wear shoes without heels.
• Use a cushioned sole.
Look for the following in your work chair:
• Straight back for proper alignment.
• Adjustable seat and back. People are different shapes and sizes. Being able to adjust the length of your chair, as well as the location relative to your computer monitor, can make a big difference.
• One that swivels so that you don't have to twist from your waist
• Armrests to take a load off your back.
• While sitting, try to place your knees higher than your hip. Use a stool under your feet.
• A small pillow or rolled towel behind your lower back while sitting or driving for long periods can relieve pressure.
• Move your seat as far forward as possible. This keeps you from bending forward.
• Don't recline the seat any more than a 30-degree angle.
• Stop and walk around every hour.
• Try not to lift heavy objects just after your ride.
There are a variety of options for medications. Together, you and your doctor will figure out what will work best.
It is best to start with the mildest medications available. Your doctor will likely tell you to try acetaminophen (Tylenol), aspirin, ibuprofen (Advil, Motrin), or naproxen (Aleve) initially. You don't need a prescription for these drugs. Many people tolerate them well for a short period of time. There are a few instances, however, when you should not take these medicines:
• If you have a history of bleeding from your stomach, an ulcer, or inflammation of your stomach or elsewhere along your digestive tract.
• If you drink alcohol regularly or have a history of a liver disorder.
• If you have a kidney disorder
Prescription pain relievers
If over-the-counter medications are not enough for the pain, your doctor may consider prescription pain relievers. These include:
• Non-steroidal anti-inflammatory drugs (NSAIDs) -- Over-the-counter ibuprofen is an NSAID. Prescription versions can be stronger and longer acting. Drugs in this class include diclofenac (Voltaren), etodolac (Lodine), indomethacin (Indocin), ketoprofen (Orudis, Oruvail), nabumetone (Relafan), naproxen (Anaprox, Naprosyn), piroxicam (Feldene), salsalate (Disalcid), sulindac (Clinoril), Ketorolac (Toradol) and tolmetin (Tolectin). These drugs can increase your risk for stomach ulcers and bleeding. They may also raise your blood pressure and damage your kidneys.
• COX-2 inhibitors -- This is a selective NSAID that reduces inflammation and pain. This medicine is safer for your stomach. The only NSAID currently available is celecoxib (Celebrex). Serious questions have been raised about the safety of COX-2 inhibitors. Two of these drugs were pulled from the market. The FDA ordered the manufacturer of celecoxib to add a warning to the drug's label indicating the drug may increase the risk for heart problems or stroke.
• Narcotics -- Drugs in this category include codeine, meperidine (Demerol), morphine (MS Contin), oxycodone (Percocet, Percodan), and tramadol (Ultram). These medications often cause constipation and can be addictive. Although they relieve pain, they do not generally improve activity level.
If pain relievers alone are not enough, your doctor may consider a type of drug called a muscle relaxant, especially if you have a lot of muscle spasm (tension in your muscles). Examples of muscle relaxants include:
• Cyclobenzaprine (Flexeril)
• Diazepam (Valium)
• Carisoprodol (Soma)
• Methocarbamol (Robaxin)
Interestingly, muscle relaxants don't actually work at the muscles. They work by telling your brain to relax the muscles. These medications have the potential for abuse and addiction, particularly if they are taken for a long period of time. Drowsiness is a common side effect.
If your back pain persists for longer than a month, your doctor may consider injecting a steroid drug in the area of the pain. This medication reduces inflammation and pain. The doctor may consider this if you have a trapped nerve. Sciatica is an example of back pain with a trapped nerve. A nerve may also become trapped if you have a herniated disk.
Seeing a chiropractor, acupuncturist, or massage therapist for back pain has become increasingly popular. For certain individuals, these methods may be beneficial, especially if you have a strong belief that one of them will work.
Each of us responds to pain (and the various methods available to relieve it) differently. Here is a brief overview of what the science is saying about specific pain control methods.
• Spinal manipulation by either a chiropractor or an osteopathic doctor may be helpful if you have had low back pain for at least 2 - 3 weeks. Manipulation is a manual technique that moves a joint beyond the end point of its normal range of motion. Spinal manipulation refers to manipulation of the vertebrae (spinal bones).
• Acupuncture, a technique that involves inserting extremely thin needles into "energy" points in the body, has become very popular for pain control. There are only a few small studies that have looked at the value of acupuncture for back pain specifically. At this point, it is hard to draw conclusions from the research. Some individuals may benefit by using acupuncture to relieve back pain. In particular, it may be worth trying if you cannot take medications (for example, if you cannot take NSAIDs).
• Massage therapy, especially when combined with regular exercise, can help relieve both acute and chronic low back pain. Talk to your doctor about when it is safe to try. Look for a licensed, certified massage therapist in your area. Also, most physical therapists do limited, local massage around the area of your pain.
There are conditions for which surgery may be considered. These include:
• Herniated disk
• Narrowing of the spine (spinal stenosis)
• Degenerative or failing disks that are painful
• Arthritis of the spine
• Instability of the spine
Too much, too little, just right
Lack of regular physical activity, often called a sedentary lifestyle, puts you at greater risk for getting back pain. This is because lack of exercise leads to:
• Weak stomach and back muscles
• Inflexible back muscles, which limit your ability to turn and bend down
• Becoming overweight, which puts additional stress on your spine, especially increased abdominal size
High intensity exercise or doing movements improperly may also lead to back pain.
Many cyclists also have back pain. This may be avoided by proper adjustment of your bicycle seat and maintaining good flexibility of your back and hamstring muscles.
Using poor form or posture for any activity, including golfing or lifting weights, can cause serious problems with your back.
What should you do?
• Vary your workout.
• Work with a knowledgeable trainer until you have learned the proper movements and form for the activities you do.
• Do low-impact aerobics like swimming, bicycling, and walking. These strengthen back and stomach muscles without over-straining the back. Swimming may be particularly good.
• Include appropriate stretching and strengthening in your workout routine after you have recovered from the acute phase of your back pain. A physical therapist can be a big help in this area.
• Consider yoga, Tai Chi, or Chi Kung. These are Indian and Chinese forms of exercise that combine low-impact movements with meditation and relaxation. Look in your area for a class. Your doctor or physical therapist may be able to help you find one.
Drug treatment – NSAIDs
Nonsteroidal Anti-inflammatory Drugs (NSAIDs) are the most commonly used type of medication for back pain. They work by blocking a substance called prostaglandin. Normally, prostaglandins dilate blood vessels (leading to increased blood flow) and promote inflammation, both of which can contribute to pain. By stopping the usual actions of prostaglandins, NSAIDs help reduce pain and inflammation.
Types of NSAIDs
NSAIDs are available over-the-counter or by prescription. They are either seletive or non-selective. The prescription versions are generally stronger and last longer.
Non-selective NSAIDs include:
• Diclofenac (Voltaren)
• Etodolac (Lodine)
• Ibuprofen (Advil, Motrin, Motrin IB, Nuprin)
• Indomethacin (Indocin)
• Ketoprofen (Orudis, Oruvail)
• Nabumetone (Relafan)
• Naproxen (Aleve, Anaprox, Naprosyn)
• Piroxicam (Feldene)
• Salsalate (Disalcid)
• Sulindac (Clinoril)
• Tolemetin (Tolectin)
Selective NSAIDs include:
• COX-2 Inhibitors, such as celecoxib (Celebrex)
Risk of ulcers and GI bleeding
Regular use of non-selective NSAIDs, especially long-term use, can have serious complications like ulcers, bleeding from your gastrointestinal (GI) tract, and kidney damage. (Selective COX-2 inhibitors, however, may be associated with a lower risk of ulcers and gastrointestinal bleeding.) You are at particular risk of developing ulcers from these drugs (including bleeding ulcers) if you:
• Are over age 60
• Have had an ulcer in the past or history of bleeding from your GI tract
• Drink alcohol on a regular basis
• Take certain medications, such as warfarin (Coumadin), steroids, or alendronate (Fosamax)
Other possible side effects
NSAIDs can cause or worsen the following conditions:
• Cardiovascular: Evidence from large research trials has showed increased rates of fatal and non-fatal cardiovascular events and heart attacks in patients taking NSAIDs.
• High blood pressure: NSAIDs can increase blood pressure. If you have high blood pressure, check with your doctor before using NSAIDs, especially if you take blood pressure lowering medication.
• Kidney disease: NSAIDs can cause kidney damage. If you already have any type of kidney disease, don't use NSAIDs. If while taking an NSAID, you develop sudden weight gain or fluid retention (for example, you notice swelling in your legs), notify your doctor right away.
• Diabetes: NSAIDs can cause a change in blood sugar. Check with your doctor before using NSAIDs if you have diabetes. You may still be able to use them, but you may need to follow your blood sugars closely and, with the help of your doctor, adjust your diabetes medications appropriately.
Finally, NSAIDs can cause:
• Tinnitus (ringing in your ear)
• Skin rash
Drug treatment - COX-2 inhibitors
COX-2 inhibitors are a special class of NSAIDs that block the body's production of a substance that causes inflammation and pain. They are less likely to cause stomach ulcers and gastrointestinal bleeding than other NSAIDS. COX-2 inhibitors are much more expensive than standard NSAIDs like ibuprofen. Celecoxib (Celebrex) is a COX-2 inhibitor.
Possible side effects
COX-2 inhibitors can cause the following side effects:
• Heart attack and stroke. Several COX-2s have been taken off the market due to the risk of fatal and non-fatal cardiovascular events. The FDA asked the manufacturer of Celebrex to place a strong warning on its label to alert patients to the potential for such risks.
• Stomach pain and diarrhea.
• Poor kidney function, especially if you are over 65 years old. If you develop fluid build up, notify your doctor right away.
• Negative interactions with medications for high blood pressure, heart disease, and seizures. Make sure that the doctor prescribing COX-2 inhibitors knows about all of the other drugs you are taking.
People who should not use COX-2 inhibitors
If you are allergic to NSAIDs, sulfa drugs, or aspirin, you cannot take COX-2 inhibitors. Also, if you are pregnant or planning to become pregnant in the near future, you should not use COX-2 inhibitors.
If you had a heart attack or have a history of blockages in your coronary arteries, ask your doctor if COX-2s are right for you. People with a history of other heart conditions or risk factors, such as diabetes, high blood pressure, or high cholesterol, should use COX-2 inhibitors with caution.
Drug treatment - muscle relaxants
Sometimes, your doctor will prescribe muscle relaxants in combination with an NSAID or other drug for pain and inflammation when you first have back pain. They work through the central nervous system (brain and spinal cord) to tell your muscles to relax. They do not work directly at the muscles. They have been shown to be effective at relieving muscle spasm and pain in patients with acute back pain.
Examples of muscle relaxants include:
• Carisoprodol (Soma)
• Cyclobenzaprine (Flexeril)
• Diazepam (Valium)
• Methocarbamol (Robaxin)
Possible side effects
Side effects from muscle relaxants are common and include:
• Nausea or vomiting
These medicines also have the potential for abuse and addiction.
You should not drive or operate heavy machinery while taking muscle relaxants. You should also not drink alcohol while taking these medications.
People who should not use muscle relaxants
You should not take muscle relaxants if you have:
• Hyperthyroidism (an over-active thyroid gland)
• Heart failure
• An abnormal heart rhythm (arrhythmia)
You should also not use this type of drug if you take a monoamine oxidase (MAO) inhibitor (like isocarboxazid, phenelzine, and tranylcypromine), used for depression.
If you are pregnant, planning to become pregnant in the near future, or breastfeeding, do not use muscle relaxants.
Drug treatment – narcotics
Narcotics, also called opioid pain relievers, are reserved for pain that is severe and not helped by other types of painkillers. Narcotics work by binding to receptors in the brain, blocking your feeling of pain and, therefore, your limitations from pain. These drugs do have the potential for abuse and addiction. Addition, however, is less of a problem than once thought when these medicines are used as prescribed for relief of pain. While these medicines should be used carefully and only under the direct supervision of a doctor, they can be effective at reducing pain.
Examples of opioids include:
• Fentanyl (Duragesic) - available as a patch
• Meperidine (Demerol)
• Morphine (MS Contin)
• Oxycodon (Oxycontin, Percocet, Percodan)
• Tramadol (Ultram)
Possible side effects
In addition to the risk of addiction, opioids can cause:
• Impaired judgment
• Nausea or vomiting
When taking narcotics, do not drink alcohol, drive, or operate heavy machinery.
Pain relief – acupuncture
Acupuncture is a treatment based on Traditional Chinese Medicine (TCM), a system of healing that dates back thousands of years.
Acupuncture gained the attention of the American public after President Nixon's trip to China in 1972. Traveling with Nixon was a New York Times reporter, James Reston, who received acupuncture in China after undergoing an emergency appendectomy. He was so impressed with the procedure's ability to relieve his postoperative pain that he wrote about his experience upon returning to the United States.
Acupuncture was formally recognized as part of mainstream medicine's range of healing options in 1997, when the National Institutes of Health issued a statement documenting its safety and effectiveness for a range of health conditions. Research comparing the effectiveness of acupuncture to other treatments -- including physical therapy, massage therapy, and standard medical treatment -- has not shown a clear benefit, however.
How does acupuncture work?
The effects of acupuncture are complex, and how it works is not entirely clear. Research suggests that the placement of needles, and other modalities used in acupuncture, may produce their complex effects on a wide variety of ways in the brain and the body. For example, it is theorized that stimulated nerve fibers signal the spinal cord and brain to release certain hormones responsible for making us feel better overall and, more specifically, feel less pain. In fact, a study using images of the brain confirmed that acupuncture increases our pain threshold, which may explain its ability to produce long-term pain relief.
As explained by TCM, there is a type of life force, or energy, known as qi (pronounced "chee") that flows through energy pathways in the body called meridians. Each meridian corresponds to one specific organ, or group of organs, that governs particular bodily functions. The proper flow of qi is thought to create health. An imbalance of qi (too much, too little, or blocked flow) results in disease. In acupuncture, needles are inserted at points along the meridians to restore balance to the qi. Acupuncture points, or the specific locations where needles are inserted, are places where the energy pathway is close to the surface of the skin.
What does an acupuncturist do?
In addition to asking questions, the acupuncturist may want to take your pulse at several points along the wrist and look at your tongue to observe its shape, color, and coating. The acupuncturist may also observe the color and texture of your skin, your posture, and other physical characteristics that offer clues to your health.
The acupuncturist then asks you to lie down on a padded examining table, and inserts the needles, twirling or gently jiggling each as it goes in. You may not feel the needles at all, or you may feel a twitch or a quick twinge of pain that subsides as soon as the needle is completely in. Once the needles are all in place, you rest for 15 - 60 minutes. During this time, you'll probably feel relaxed and sleepy and may even doze off. At the end of the session, the acupuncturist quickly and painlessly removes the needles.
How many treatments do I need?
For chronic back pain, one or two treatments a week for 1 to 2 months may be recommended.
What is acupuncture good for?
Acupuncture has been found to help some patients with chronic low back pain.
You can safely combine acupuncture with prescription drugs and other conventional
treatments, but it is important for your primary care physician to be aware of and to monitor how your acupuncture treatment may be affecting your conventional therapies.
Should anyone avoid acupuncture?
Some physicians and practitioners may avoid treatment during pregnancy. If you have been seen by a particular practitioner prior to your pregnancy, however, it is generally safe to continue receiving treatment from that practitioner during your pregnancy.
Should I watch out for anything?
Be sure your acupuncturist uses only disposable needles. In addition, if your acupuncturist is qualified to prescribe herbs and would like you to take them as part of your treatment, first discuss this with your physician. Herbs are potent substances that can be harmful if you suffer from certain conditions. They can also interact with drugs you may be taking and cause side effects.
How can I find a qualified practitioner?
Most states require acupuncturists to be licensed and confer a title (LAc) that these acupuncturists can use to identify themselves. The American Academy of Medical Acupuncture (www.medicalacupuncture.org) can provide a list of licensed physicians in your area who are also trained to perform acupuncture. The American Academy of Orthopaedic Surgeons may also have a list of physicians who are trained in acupuncture (www.aaos.org). Your doctor may also be able to help.
The National Certification Commission for Acupuncture and Oriental Medicine certifies acupuncturists (Dipl Ac) and practitioners of Chinese herbal medicine (Dipl CH) upon passing a qualifying exam. To find certified practitioners, go to www.nccaom.org.
Does my medical insurance cover acupuncture treatments?
An increasing number of insurance providers and HMOs now cover all or part of the cost of acupuncture treatments, but these providers may have restrictions on the types of illnesses they cover. Check with your insurance company to see what your policy offers.
Pain relief - chiropractic therapy
Chiropractic is a method for diagnosing and treating illnesses that affect the nerves, muscles, bones, and joints of the body. Daniel David Palmer founded chiropractic in 1895. Palmer was a self-taught healer who was studying spinal structure and manipulative techniques when he cured a man of deafness and acute back pain by realigning a displaced vertebra in his back. This and other successes led Palmer to believe that most diseases were a result of abnormal nerve transmission caused by "vertebral subluxation" (that is, misalignment of the spine).
Although most contemporary chiropractic practices have introduced additional therapies, spinal manipulation remains the essence of chiropractic. Today, chiropractic is the third largest independent health profession in the Western world, and the United States alone is home to 52,000 licensed chiropractors who together see 20 million patients a year.
What happens during a visit to a chiropractor?
The first visit typically lasts about an hour. The chiropractor takes a complete health history, including:
• Information on past injuries and illnesses
• Current conditions and medications
• Sleep habits
• Mental stresses
• Use of alcohol, drugs, or tobacco
During a physical exam, the chiropractor also tests the extent of spinal mobility and may perform various diagnostic tests, such as blood pressure and x-rays, to rule out other conditions. Treatment generally begins at either the first or second visit. Patients are typically asked to lie on a specially designed table, where the chiropractor performs the spinal manipulations.
The most common maneuver is manual manipulation, which involves movement of the selected joint to the end of its range, followed by a low-force thrust. The chiropractor may, however, use other treatments including massage and soft-tissue therapies. Some people experience minor aches, stiffness, and tiredness for a few days after the manipulation while their body adjusts to the new alignment.
How many treatments will be required?
More than one session is usually needed to correct a problem; a typical course of treatment lasts several weeks. The chiropractor may suggest two or three sessions a week (lasting only about 10 - 20 minutes), then reduce the frequency to weekly sessions once the condition being treated improves. Patient and chiropractor together evaluate the effectiveness of treatment based on the goals discussed in the first session.
What conditions are treated effectively with chiropractic?
Chiropractic has been shown to be effective for subacute back pain and flare-ups of chronic low back pain. It is also effective for neck pain. Manipulation of joints and the body’s soft tissues may also be helpful for pain from other conditions, such as frozen shoulder, tennis elbow and other sports injuries, and carpal tunnel syndrome.
Who should not be treated with chiropractic?
Individuals with bone fractures or tumors, acute arthritis, bone or joint infections, or advanced osteoporosis should avoid chiropractic therapy in areas affected by any of these conditions.
Patients should also tell their chiropractor about any physical disabilities they have, or if they are experiencing symptoms of numbness, tingling, weakness, or other neurological problems.
In extremely rare cases, manipulation of the neck has damaged blood vessels or caused strokes. The screening process, however, is designed to detect people at high risk for such problems and avoid neck manipulation.
How can a qualified practitioner be located?
Chiropractors are licensed in all 50 states. A chiropractic degree requires approximately the same number of educational hours as a medical degree. The chiropractic program includes clinical experience, basic sciences, and the ability to diagnose structural (spinal) and functional (nervous system) problems.
At least one chiropractic organization serves each state in the U.S. The largest association in the profession of chiropractic is the American Chiropractic Association (ACA). For a list of licensed chiropractors in your area, visit the ACA's web site at www.amerchiro.org.
You can also check with the American Academy of Orthopaedic Surgeons (www.aaos.org). Your doctor may also be able to help.
Pain relief – massage
Massage is a "hands-on" therapy in which muscles and other soft tissues of the body are manipulated to improve health and well-being. Varieties of massage range from gentle stroking and kneading to deeper manual techniques. Massage has been practiced as a healing therapy for centuries in nearly every culture around the world. It helps relieve muscle tension, reduce stress, and evoke feelings of calmness.
Although massage affects the body as a whole, it particularly influences the activity of the musculoskeletal (muscles, tendons, ligaments, and bones), circulatory (blood flow), lymphatic (waste drainage), and nervous systems.
Are there many types of massage?
There are nearly 100 different massage and body work techniques. Each technique is uniquely designed to achieve a specific goal. Some common types that might help your back pain include:
• Aromatherapy massage: Essential oils from plants are massaged into the skin in order to enhance the healing and relaxing effects of massage.
• Craniosacral massage: Gentle pressure is applied to the head and spine to correct imbalances and restore the flow of cerebrospinal fluid (fluid that surrounds your brain and spinal cord) in these areas.
• Myofascial release: Gentle pressure and body positioning are used to relax and stretch the muscles, fascia (connective tissue), and related structures. Both physical therapists and massage therapists who are appropriately trained use this technique.
• On-site/chair massage: Popular in offices and other public places, on-site massage therapists use a portable chair to deliver brief, upper body massages to fully-clothed people.
• Shiatsu: Gentle finger and hand pressure are applied to specific points on the body to relieve pain and enhance the flow of energy (known as qi in Chinese medicine) through the body's energy pathways (called meridians). Shiatsu is widely used in Traditional Chinese Medicine (TCM).
• Swedish massage: A variety of strokes and pressure techniques are used to enhance the flow of blood to the heart, remove waste products from the tissues, stretch ligaments and tendons, and ease physical and emotional tension.
• Trigger point massage: Pressure is applied to "trigger points" (tender areas where the muscles have been damaged) to alleviate muscle spasms and pain.
How does massage work?
When a practitioner massages soft tissue, electrical signals are transmitted both to the local area and throughout the body. These signals help heal damaged muscle, stimulate circulation, clear waste products via the lymphatic system, boost the activity of the immune system, reduce pain and tension, and induce a calming effect. They may also enhance a general sense of well-being by stimulating the release of endorphins (natural pain-killers and mood elevators) and reducing levels of certain stress hormones.
What happens during a massage therapy session?
At your first massage therapy session, the practitioner will ask you about any symptoms you may have (like low back pain) and will also ask questions about your medical history. The practitioner may also initiate a discussion about what you expect to achieve from the massage session.
The therapist leaves the room while you undress and lay down on the massage table. A sheet is used as a drape during the session and is moved only to expose the part of the body being worked on at any given time. Massage oil or lotion is often used to reduce friction between the practitioner's hands and your skin. The room is kept warm and free of distractions. The therapist may have soft music playing in the background and frequently asks whether he or she is applying too much or too little pressure.
The manner in which a practitioner massages your body depends on the problem being treated. A massage session can last from 15 to 90 minutes and may include a schedule of follow-up visits, depending on the severity of your situation.
What is massage good for?
In general, massage is believed to support healing, boost energy, reduce recovery time after an injury, ease pain, and enhance relaxation, mood, and well-being. It is a treatment option that may relieve chronic low back pain.
Are there any risks associated with massage?
In general, massage is considered relatively safe. Pain or other rare negative side effects are generally caused by an extremely vigorous massage technique.
Women should be cautious about receiving massages during pregnancy. If you are pregnant, be sure to find a therapist specifically trained to perform massages on pregnant women.
Even though massage is a useful technique to help regulate blood sugar over time, if you have diabetes you should check your blood sugar after a massage session because it may be too low just following a treatment. Plus, if you have diabetes and you are receiving massage on a regular basis, you should check your blood sugar frequently to evaluate for any changes over time.
Should anyone avoid massage?
Massage should be avoided by people with:
• Heart failure
• Kidney failure
• Infection of the superficial veins (called phlebitis) or soft tissue (called cellulitis) in the legs or elsewhere
• Blood clots in the legs
• Bleeding disorders
• Contagious skin conditions
If you have cancer, you must check with your doctor before considering massage because you should not receive such treatments under certain circumstances. For example, sometimes massage can damage tissue that is fragile from chemotherapy or radiation treatments.
People with rheumatoid arthritis, goiter (a thyroid disorder characterized by an enlarged thyroid), eczema and other skin lesions should not receive massage therapy during flare-ups. Experts also advise that people with osteoporosis, high fever, few platelets or white blood cells, and mental impairment, as well as those recovering from surgery, may be better off avoiding massage.
Also, be sure to let your massage therapist know any medications you are taking as the treatment may influence absorption or activity of both oral and topical medicines.
How can I find a practitioner?
Certified massage therapists complete a training program of 500 or more hours, take national board exams, and are licensed or registered in more than 30 states and the District of Columbia. To find a massage therapist in your area, visit the American Massage Therapy Association web site at www.amtamassage.org.
Pain relief – osteopathy
Osteopathy is based on the belief that most diseases are related to problems in the musculoskeletal system and that structure and function of the body are inseparable.
The musculoskeletal system is comprised of the muscles, bones, and soft-tissues like cartilage, tendons, and ligaments. All of these structures are interconnected and form the body's framework. Nerves originating in the spinal cord create an important network throughout the body and are highly connected to the musculoskeletal framework.
Doctors of osteopathy (D.O.s) receive the same basic training as medical doctors (M.D.s). D.O.s also learn manipulation therapies (hands-on adjustments of muscles, bones, and ligaments), using these in addition to more conventional medical treatments. Most D.O.s are primary care practitioners, specializing in family medicine, internal medicine, obstetrics/gynecology, or pediatrics. A few can be found in other medical specialties as well. D.O.s have full practice rights in all 50 states.
Although osteopathic manipulations were originally intended and used to treat all forms of disease, now they are mainly considered useful for musculoskeletal conditions.
How does osteopathy work?
Long nerves connect the spine to various organs in the body. According to Andrew Taylor Still, the founder of osteopathy, when problems arise in the spine the nerves send abnormal signals to the body's organs. Still called these spinal problems "osteopathic lesions" ("osteo" for bone and "pathic" for diseased), and devised osteopathic manipulation techniques (OMTs) to treat them. Such lesions are detected by the osteopathic doctor from abnormal texture of the skin and other soft tissues of the body as well as from restricted range of motion in the joints.
OMTs range from light pressure on the soft tissues to high-velocity thrusts on the joints. These treatments, he believed, would return the nerves to their normal function and allow the blood to flow freely throughout the circulatory system. Mr. Still theorized that with structure restored, the body's own natural healing powers are then able to restore the entire body to full health.
What happens during a visit to the osteopath?
A visit to a D.O. is much like a visit to your family doctor. The D.O. will ask you questions about your medical history, physical condition, and lifestyle. However, because D.O.s have particular expertise in musculoskeletal systems (namely, bones, joints, and soft tissues like ligaments and tendons), the physical exam of that bodily system will likely be more extensive.
During the physical, the D.O. will assess your posture, spine, and balance; check your joints, muscles, tendons, and ligaments; and may use their hands to manipulate your back, legs, or arms. If needed, the D.O. will order x-rays and laboratory tests.
When the results are in, the D.O. will make a diagnosis and establish a treatment plan for you that may even include prescriptions for medications.
For problems involving the bones, muscles, tendons, tissues, or spine, many (but not all) D.O.s use OMTs. There are two categories of OMT procedures: direct and indirect. In direct OMT, "problem" or "tight" tissues are moved (by the D.O., the person being treated, or both) toward the areas of tightness or restricted movement. In indirect OMT, the D.O. pushes the "tight" tissues away from the area of restricted movement, in the opposite direction of the muscle's resistance. The D.O. holds the tissues in this position until the tight muscle relaxes.
What illnesses and conditions respond well to osteopathy?
OMTs may be effective for back and neck pain. In fact, if you have back pain, you may be able to reduce the amount of pain medication you are taking if you receive OMT as part of your therapy.
Who should not be treated with osteopathy?
You should avoid osteopathic manipulation if you have a broken bone or dislocation, bone cancer, a bone or joint infection, damaged ligaments, rheumatoid arthritis of the neck, or osteoporosis. Osteopathic manipulation is also not recommended for people who recently underwent joint surgery or for people taking an anticoagulant (blood thinning) medication.
Are there risks associated with osteopathy?
Shortly after an OMT treatment you might feel an increase in pain, slight headache, or fatigue. These symptoms are temporary, and generally disappear within a day. More serious adverse events of stroke and spinal injury have been reported following manipulation of the neck; this complication is extremely rare.
How can I find a qualified practitioner?
To locate a licensed D.O. in your area that has been trained in one of the 19 medical schools and 200 teaching hospitals approved by the American Osteopathic Association (AOA), visit the AOA's web site at www.osteopathic.org.
For additional information or referrals, visit the American Academy of Osteopathy web site at www.academyofosteopathy.org, or the American College of Osteopathic Family Physicians web site at www.acofp.org.
Reducing stress may be a help
Learn to relax
Methods for relaxation can reduce pain and improve your mood. Such methods may even help you sleep more comfortably. Consider:
• Listening to relaxing music.
• Using guided imagery (a form of visualization; there are audiotapes available to guide you).
• Trying progressive relaxation (a process where you tense and then relax all of the muscles in your body. The result is a greater sense of calmness and more relaxed muscles).
• Practicing yoga, tai chi, or chi kung. These are Indian and Chinese exercise programs that combine low-impact movement with meditation, breathing, and other forms of relaxation. They may help both your body and your mind experience less pain.
What is sciatica?
Sciatica is pain that runs along your leg and often accompanies low back pain. The sciatic nerve is a large nerve (as wide as your thumb) that is made up of branches from the lowest part of the spinal cord (the lumbar and sacral areas -- see step 2). The nerve travels through the pelvis, deep below the buttocks, passing down the hip and along the back of the thigh all the way to your foot.
If the sciatic nerve gets trapped or inflamed anywhere along this route, you may feel pain. This is called sciatica. There are several ways that a low back injury may press on the sciatic nerve and cause sciatica. Two common reasons are a herniated disk and spinal stenosis (narrowing of the spinal canal).
Sciatica can also result from a sudden injury. For example, if a buttocks muscle is injured from running too hard or lifting too many weights, it may swell or tighten and put pressure on the sciatic nerve causing pain.
Sciatica causes pain anywhere along the route that the sciatic nerve travels (your buttocks, the back of your thigh, the back of your calf, and even your foot). The sensation may be only a slight tingling or dull ache or it may be severe enough to decrease your ability to move. Sciatica almost always affects one leg or the other. Sometimes, however, you may have symptoms in both legs.
When is surgery necessary?
Surgery may be considered if you have back pain from a herniated disk, spinal stenosis, or sciatica that does not respond to medication or physical therapy. Even though surgery is an option for these conditions, treating them without surgery is better whenever possible. In fact, 90% of people with a herniated disk can be treated without surgery.
Laminectomy and laminotomy
Operations that remove all (laminectomy) or part (laminotomy) of the arch of the vertebrae may be used if you have spinal stenosis or some other vertebral abnormality pressing on a nerve. This surgery may also be considered as part of a larger procedure to remove a tumor on the spine. Like diskectomy, many people will feel immediate relief after the procedure. However, recurrent back pain is very common.
This surgical procedure removes the disk that is causing your pain. By doing this, pressure on your spine is relieved. There are now ways to perform this surgery with as little invasion as possible. For example, very small incisions may be used.
While there may be an immediate relief from pain following this operation, it is not clear whether this provides any more long-term improvement than treatment with medications, physical therapy, exercise, and the other measures discussed in this guide.
Following the procedure, you may develop scar tissue, which could cause back pain itself. You will need to do a lot of resting for 3 - 4 days after this surgery. But, it may take 4 - 6 weeks to fully recover.
When motion between two or more vertebrae causes severe pain, your surgeon may recommend spinal fusion. Spinal fusion may also be done, if you have surgery to remove a disk or some bone, to prevent motion from occurring between two vertebrae.
This procedure eliminates motion between the bones of the back by eliminating the joints between the bones and forming a solid bony bridge. This is usually done by using a combination of metal implants, like screws and rods, and grafting bone onto the spine from another part of your body. The bone often comes from your pelvis.
Recovery from this procedure usually takes longer than from diskectomy or laminectomy. Your surgeon may recommend you wear a brace after surgery as the bone heals. This type of surgery is usually for people with chronic back pain that has not responded to other treatments. Spinal fusion may also help people who have instability of the spine, a condition that occurs when the connections between the vertebrae have deteriorated. The procedure allows vertebrae to slide back and forth against each other.
The artificial disk is a newer method of spine surgery. This implanted device is an alternative to fusion for some people.
Sometimes, a degenerated disk that is causing back pain needs to be removed through surgery. However, when a disk is removed, the vertebrae in that area of the spinal column must be re-connected. Typically, surgeons will use spinal fusion to reconnect the vertebrae, which eliminates motion between the vertebrae. The artificial disk, however, preserves motion between the vertebrae.
While experts believe there are many advantages to preserving motion, no long-term studies prove that replacing a disk with an artificial one is better than spinal fusion. Some surgeons are waiting for the results of more research, particularly longer-term follow-up of more patients to make sure there are no serious complications, before recommending this new technology.
Exercises to maintain back health
Once you have gotten through the initial stages of back pain, learning exercises to make your back stronger and more flexible can help you avoid getting pain again. Talk to your doctor and physical therapist about when it is safe to begin strength training and stretching. When you have been given the green light, try the following exercises at least three times per week.
1. Lie on the floor with your back flat. Bend your knees. Cross your hands over your chest.
2. Raise your shoulders 3 - 6 inches off of the floor. Exhale on the way up (while your abdominal muscles are contracted/tightened).
3. Inhale on the way down.
4. Do this slowly at least 8 - 10 times.
As you get stronger, you can gradually increase the number of repetitions.
1. Lie on your back, bend your knees, and keep your feet flat on the floor.
2. Press your lower back into the floor. Tighten your buttocks muscles.
3. Hold for one second and then relax.
Over time, you can make this exercise harder by holding for 5 seconds or longer. Putting your feet farther away from your body also makes this more difficult.
Low back stretch #1
1. Lie on your back with your knees bent and legs together. Keep your arms at your sides.
2. Slowly roll your knees over to one side.
3. Hold for 10 - 20 seconds. Repeat to the other side.
Low back stretch #2
1. Lie on your back with your knees bent and feet flat on the floor.
2. Hold one knee and gently bring it toward your chest.
3. Hold for 10 - 20 seconds. Repeat with the other knee.
Low back stretch #3
1. Facing the floor, support your body with your hands and knees.
2. Lift and straighten your right hand and left leg at the same time. Tighten your stomach muscles. Keep your back straight.
3. Hold for 3 seconds. Change sides and repeat. You can do this up to 20 times on each side.
How to lift and bend
To prevent back pain, follow these tips for how to lift and bend:
• If an object is too heavy or awkward, get help.
• Spread your feet apart to give a wide base of support.
• Stand as close to the object you are lifting as possible.
• Bend at your knees, not at your waist.
• Tighten your stomach muscles as you lift the object up or lower it down.
• Hold the object as close to your body as you can.
• Lift using your leg and buttock muscles.
• As you stand up with the object, don't bend forward.
• Do not twist while you are bending for the object, lifting it up, or carrying it.
How to prevent low back pain
If your work involves heavy lifting, sitting at the computer for long stretches, or driving far distances, you are at risk for low back pain. Take the following steps and you may be less likely to develop back troubles.
1. Use good posture at all times. This is important when you are standing or sitting because the muscles in your back and the bones in your spine are always working to keep your body upright.
2. Take care when lifting. See: Tips for How to Lift and Bend.
3. Exercise regularly. Remember that finding the right balance is important. Finding balance also means doing exercises that don't strain your back, like swimming, walking, and cycling with proper seat adjustment. Always include a warm up, back stretches, and cool down.
4. Lose weight. Carrying extra pounds, especially around your waist, puts additional stress on your spine.
5. Quit smoking. Cigarettes put you at increased risk for back problems. This may be because tobacco causes poor blood circulation. Or, it may be because when you smoke, you are more likely to have other bad habits, like not exercising.
6. Sleep wisely. This means sleeping on your side, not your stomach, on a firm mattress. If you are only comfortable sleeping on your back, use a pillow under your knees for support.
7. Learn to relax. Stress and unhappiness at home or work make it more likely that you'll develop back pain. It is important, therefore, to practice some form of relaxation regularly. Listen to calming music, meditate, or do tai chi. See: Reducing stress may be helpful.
8. Consider a lumbar support belt. Sometimes, if you have had back pain related to your job, it helps to wear a support belt while you are lifting or performing the activities that bring on your back pain. The science about this is controversial, meaning that it works for some and doesn't work for others. Talk to your doctor about whether it is right for you. If you do regular stretching and strengthening and you haven't had back pain in a long time, it is probably not necessary to use such a belt.
Preparing for your doctor visit
Knowing the types of questions that your doctor may ask can help you feel more prepared. See the list below to get a sense of what information will be important to your doctor. Your answers to these questions will help your doctor figure out next steps -- for example, what treatment is best, what tests to order, if you need to see a physical therapist, if you need to see a specialist. You can make your visit more efficient if you think about your answers before going to the doctor.
• Did you have a particular injury or accident?
• Have you ever had back pain before?
• How long have you had the pain this particular time?
• What were you doing just before the pain began? Were you lifting or bending? Sitting at your computer? Driving a long distance?
• If you have had episodes of back pain in the past, how often do you tend to get them? How long does each episode usually last?
• What does the pain feel like? (For example, is it dull, sharp, throbbing, or burning?)
• What makes the pain worse?
• What makes the pain feel better?
• Is there any particular time of day when the pain feels better or worse?
• Do you have any numbness or tingling?
• Have you noticed any weakness in your legs?
• Have you lost weight recently without trying?
• Have you had a fever?
• Do you have any urinary symptoms like going to the bathroom more often than usual? Do you have a burning sensation when you urinate?
• Have your bowel habits changed?
• Has there been a change in your walking or ability to balance?
Low back pain: Key points
• Almost everyone has back pain at some time in their life. In fact, it is the #2 reason why Americans see the doctor.
• The low back is the most common area to be affected by pain. This is because the low back supports the weight of your head, trunk, and arms.
• Along with your low back pain, you may feel numbness, tingling, or weakness in your legs or feet. If you do, you should notify your doctor.
• A single, sudden movement may lead to the feeling of pain. However, this pain may be a result of poor posture, such as using improper form while standing, sitting, lifting, or other activities. The specific cause of back pain is usually not identified.
• Lots of people have spine problems, like bulging disks. But not everyone experiences pain from them.
• Most episodes of low back pain start to improve within one week and clear up within four to 6 weeks.
• Your doctor may consider ordering tests or sending you to a specialist if you have certain warning signs or if your pain lasts longer than 1 month.
• Getting back pain more than once (called recurrent pain) is common. But there are lots of steps you can take to avoid getting back pain again.
• Back pain becomes more likely as you get older. But exercise, good posture, and proper movements for bending and lifting can help prevent back pain, no matter what your age.
• Stress and depression make you more likely to experience long-term, ongoing back pain. Learning to relax can help reduce your chances for back pain.
• Jobs that involve heavy lifting, lots of bending, and whole body vibration (like truck driving) can raise your chances of getting back pain. There are lots of ways to adjust these activities, if they are part of your job description. If you take such steps, you can avoid back pain.
• Lose weight and quit smoking to lower your chances of getting back pain.
• Bed rest is NOT recommended if you have back pain. Reduced activity level is only recommended for the first couple of days.
• Avoid exercise in the days immediately after your back pain begins. After 2 - 3 weeks, gradually resume exercise. You may start getting back to everyday activities after just a few days.
• Working with a physical therapist can be very helpful, especially if your pain lasts longer than 2 - 3 weeks.
Source: Ministry of Health