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Back Pain
Prevention, reduction, management

July 2009 – Vol. 13, No. 7

Editor: Janet M. Pollard, MPH

“If you are experiencing back pain, you are not alone. An estimated 75 to 85 percent of all Americans will experience some form of back pain during their lifetime.”¹ In fact, back pain is one of the most common neurological ailments in the United States – second only to headache (PDF).² Back pain is one of the most common reasons people go to the doctor or miss work;³ it is also the most common cause of job-related disability.²

Who Gets Back Pain? Risk factors

Some factors (controllable and uncontrollable) may put you at higher risk for back pain. These may include:

Age. “The first attack of low back pain typically occurs between the ages of 30 and 40.”⁴ Back pain becomes more common the older you get.^4,5
Fitness level. “Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine.”⁴
Weight. “Too much weight can stress the back and cause pain.”⁵ A diet high in calories and fat, combined with inactive lifestyle, can lead to weight gain and obesity.⁴
Heredity. Some causes of back pain, such as disc disease, can have a genetic component and can be inherited.^4,5
Race. “Race can be a factor in back problems. African American women, for example, are two to three times more likely than white women to develop spondylolisthesis, a condition in which a vertebra of the lower spine…slips out of place.”⁴ Caucasian women of northern European heritage, on the other hand, are at the highest risk of developing osteoporosis, a condition in which porous, brittle bones develop.²
Smoking. “Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.”² “Your body may not be able to get enough nutrients to the discs in your back if you smoke. Smoker’s cough may also cause back pain. People who smoke are slow to heal, so back pain may last longer.”⁵
Other disease. “Some types of arthritis and cancer can cause back pain.”5
Job. “If you have to lift, push, or pull while twisting your spine, you may get back pain. If you work at a desk all day and do not sit up straight, you may also get back pain.”⁵

Why Does It Hurt? Potential causes

“Your back is an intricate structure composed of bones, muscles, ligaments, tendons, and discs – the cartilage-like pads that act as cushions between the segments of your spine. Back pain can arise from problems with any of these component parts. In some people, no specific cause for their back pain can be found.”³

Strains and Injuries. Strains and injuries from improper lifting or sudden awkward movements are a common source of back pain. These problems may include:

muscle spasms,
sprains, and
fractures or other complications of severe injury or accident.^3,4

Structural problems. In some cases, back pain may be caused by structural problems, such as:

bulging or ruptured/herniated discs,
sciatica,
arthritis,
skeletal irregularities (e.g., scoliosis, kyphosis, lordosis, back extension, back flexion),
osteoporosis,
spondylolisthesis, or
disc degeneration.^2,3,4,5

Other Problems. Other problems that are not specific to the back but may resonate pain in the back include:

fibromyalgia,
stress (PDF),
pregnancy,
kidney stones or infections, and
endometriosis.^2,4

Rare but serious conditions. In rare cases, back pain may be related to very serious or severe problems, which may include:

cauda equina syndrome,
cancer in the spine, and
infection of the spine.^2,3,4

For more detailed information and definitions of these conditions, see Why Does It Hurt? (PDF).

When to See a Doctor: Warning Signs

Though most back pain resolves within a matter of time, there are some signs that indicate the immediate need to see a doctor. These signs include the following:

numbness or tingling;⁷
pain that goes down your leg below your knee;⁸
severe pain that doesn’t improve with rest (note: resting is not recommended for more than one to two days, since prolonged rest can make back pain worse and decrease function; individuals should resume activities as soon as possible)^7,9 or pain so intense you can’t move around;⁸
severe pain that doesn’t improve within three days;¹⁰
pain after a fall or injury;⁷or
pain plus any of these problems:
- trouble urinating;
- numbness in your leg, foot, groin, or rectal area;
- nausea, vomiting, stomachache;
- weakness;
- sweating; or
- fever;⁷ or
unexplained weight loss.^7,8

Also seek medical care for back pain if you have any of the following “red flags:”

advanced age,
disability,
history of cancer,
trauma,
prolonged use of corticosteroids, or
osteoporosis.¹¹

You may want to use the following flow chart from FamilyDoctor.org¹² as a guide in helping you know when to seek medical care, or try answering the following back pain warning sign questions from the North American Spine Society.¹³

Four work-related factors associated with increased risk of back pain and injury

“Force. Exerting too much force on your back may cause injury. If your job is physical in nature, you might face injury if you frequently lift or move heavy objects.
Repetition. Repetition refers to the number of times you perform a certain movement. Overly repetitious tasks can lead to muscle fatigue or injury, particularly if they involve stretching to the limit of your range of motion or awkward body positioning.
Posture. Posture refers to your position when sitting, standing, or performing a task. If, for instance, you spend most of your time in front of a computer, you may experience occasional aches and pains from sitting still for extended periods. On average, your body can tolerate being in one position for about 20 minutes before you feel the need to adjust.
Stress (PDF). Pressures at work or at home can increase your stress level and lead to muscle tension and tightness, which may in turn lead to back pain.”⁶

Tests & Diagnosis: What to expect at the doctor’s visit

Diagnosing the cause of back pain requires a medical history and physical examination. During the medical history, you might be asked the following questions:

Have you fallen or injured your back recently?
Does your back feel better – or hurt worse – when you lie down?
Are there any activities or positions that ease or aggravate the pain?
Is your pain worse or better at a certain time of day?
Do you or any family members have arthritis or other diseases that might affect the spine?
Have you had back surgery or back pain before?
Do you have pain, numbness, or tingling down one or both legs?⁴

During the physical exam, your doctor may:

watch you stand and walk;
check your reflexes to look for slowed or heightened reflexes, either of which might suggest nerve problems;
check for fibromyalgia by examining your back for tender points, which are points on the body that are painful when pressure is applied to them;
check for muscle strength and sensation; and
check for signs of nerve root irritation.⁴

Often, a doctor can find the cause of your pain with a physical and medical history alone.⁴ Diagnostic tests aren’t usually necessary to confirm the cause of back pain; however, if there is reason to suspect that a tumor, fracture, infection, or other specific condition may be causing your back pain, your doctor may order one or more tests (PDF) .

Watchful Waiting: Self car and non-invasive strategies

If you have back pain, it does not necessarily mean you need medical attention. Sometimes, medical care is not needed right away or at all for back pain. If you do need medical attention, it doesn’t necessarily mean that you need an invasive treatment like surgery to make you feel better.¹¹ “Most low back pain can be treated without surgery,”⁹ and surgery (depending on the type) may have only a 50–60 percent success rate or positive outcome – i.e., reduced pain and/or increased function.¹⁴

Back pain can be acute or chronic:

Acute or short term back pain usually comes on suddenly and lasts from a few days to a few weeks.^9,10 “Most acute back pain is the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and range of motion, or an inability to stand straight.”⁹
“Chronic back pain is pain that persists for more than three months. It is often progressive, and the cause can be difficult to determine.”⁹
Though as a back pain sufferer you may want to immediately seek a “quick fix” through strong medications or back surgery, watchful waiting is often required. “Watchful waiting…doesn’t mean that if you have back pain you simply do nothing and see what happens. What it may mean, though, is that if you have acute back pain, you give the pain a chance to improve with conservative, self-care approaches (see practical postural tips [PDF]). And even if you have chronic back pain, you see what active, self-care steps you can take on your own before assuming that you need a more aggressive, invasive approach (see self-care and non-invasive treatment options [PDF] ). Most people are able to deal with low-level, nagging, or even annoying back pain using self-care, adjustments, and other coping skills. You may not need any higher level of treatment unless your pain interferes with your work, your leisure, or your sleep.”¹¹

Note: If you have ‘red flag’ indications associated with your chronic low back pain,¹¹ see your doctor. You can decide together if immediate treatment is needed or if watchful waiting with self-care or non-invasive treatment is an option.

The goal of self-care and noninvasive treatment (PDF) for back pain is:

to reduce, but not necessarily eliminate, back pain;
to help improve or restore function and strength to the back so that normal routines or work and leisure activity can be resumed; and
to prevent any recurrence of injury to the back.^9,11

When Conservative Treatments Don’t Help: Pros & cons of surgery & other invasive treatments

“In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries.”⁹ “You and your doctor may discuss a surgical or other invasive approach if conservative approaches haven’t appeared to relieve your low back pain or improve your function. Your preferences, concerns, and lifestyle play a large role in determining the best choice about these more aggressive approaches. Before deciding on surgery or another invasive procedure, consider these points”¹¹ from the Mayo Clinic¹¹ (see table). For information on specific types of surgery, talk with your doctor, and see the following articles:

Consider that not all back pain lasts a long time – nor is surgery an option for many sources of back pain. “Most people will have back pain sometime during their life. And 90 percent of these people will get better, without treatment or with conservative therapies, within four to six weeks. Only 5 percent remain disabled longer than three months.”¹⁵ “In most situations, an operation won’t be considered unless conservative measures have failed, and even then it’s not often indicated.”¹⁵ For example, there are currently no effective surgical techniques for muscle- and soft - tissue related back pain.³ “Back surgery is usually reserved for times when a nerve is pinched, the spinal cord is compressed, or there’s too much movement between the spinal bones.”¹⁵ Most back problems respond to nonsurgical treatments, such as anti-inflammatory medication, ice, heat, exercises that strengthen back supporting muscles, and physical therapy. When conservative treatments don’t help, back surgery may offer relief; however, it doesn’t help every type of back pain. In fact, it is only needed in a small percentage of cases.^11,15,16

Pros & Cons of Back Surgery/Invasive Procedures

Pros	Cons
Invasive procedures to damage nerve endings can sometimes eff ectively block pain when other methods have failed.	Procedures that block pain may not be permanent; you may need the procedure repeated.
Invasive procedures may lessen pain considerably and allow you to fully participate in an active rehabilitation program.	Surgery and other invasive procedures don’t always work. Some people have good results; some show litt le change; some may even experience more pain.
Spinal fusion can stop the motion and instability in your back that cause pain.	Spinal fusion removes some of the fl exibility of your spine, which means learning some adjustments in how you move aft er surgery.
A more aggressive approach may make it possible for you to resume work and other activities that are important to you, and more quickly than a less aggressive approach.	Surgery involves recovery time, and it can have side eff ects. For example, some people experience later degeneration in the area adjacent to the spinal fusion surgery.
	Long-term outcomes may be as good with less invasive procedures, and less costly

This document is meant for educational purposes only and is not intended to replace the advice of your doctor or other health care provider.

References:

Neurosurgery Today.org (2006). Low back pain [on-line]. Retrieved April 22, 2009. From http://www.neurosurgerytoday.org/what/patient_e/low.asp.
National Institute of Neurological Disorders and Stroke (2009). Low back pain fact sheet [on-line]. Retrieved April 22, 2009. From http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm.
Mayo Clinic (2008). Back Pain [on-line]. Retrieved April 22, 2009. From http://www.mayoclinic.com/health/back-pain/DS00171.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (2005). Handout on health: Back pain [on-line]. Retrieved April 22, 2009. From http://www.niams.nih.gov/Health_Info/Back_Pain/default.asp.
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (2006). What is back pain? Fast facts: An easy-to-read series of publications for the public [on-line]. Retrieved April 22, 2009. From http://www.niams.nih.gov/Health_Info/Back_Pain/back_pain_ff.asp.
Mayo Clinic (2009). Back pain at work: Preventing aches, pains, and injuries [on-line]. Retrieved April 22, 2009. From http://mayoclinic.com/health/back-pain/HQ00955.
National Institutes of Health. Don’t let back pain get you down. In NIH News in Health, January 2007 [on-line]. Retrieved April 22, 2009. From http://newsinhealth.nih.gov/2007/January/docs/01features_02.htm.
American Academy of Family Physicians (2006). Low back pain: Tips on pain relief and prevention [on-line]. Retrieved April 22, 2009. From http://familydoctor.org/online/famdocen/home/common/pain/treatment/117.html.
National Institute of Neurological Disorders and Stroke (2009). NINDS back pain information page [on-line]. Retrieved April 22, 2009. From http://www.ninds.nih.gov/disorders/backpain/backpain.htm.
U.S. National Library of Medicine (2009). Back pain [on-line]. Retrieved April 22, 2009. From http://www.nlm.nih.gov/medlineplus/backpain.html.
Mayo Clinic (2008). Back pain guide [on-line]. Retrieved April 22, 2009. From http://www.mayoclinic.com/health/back-pain-treatment/ba99999.
FamilyDoctor.org (2009). Lower back pain [on-line]. Retrieved April 22, 2009. From: http://familydoctor.org/online/famdocen/home/tools/symptom/531.html.
North American Spine Society (2009). Back pain warning signs [on-line]. Retrieved April 22, 2009. From http://www.spine.org/Pages/ConsumerHealth/SpineHealthAndWellness/
SpineHealthIQ/BackPainWarningSigns.aspx.
U.S. National Library of Medicine (2009). Surgery often unnecessary for low back pain [on-line]. Retrieved April 22, 2009. From http://www.nlm.nih.gov/medlineplus/news/fullstory_80352.html.
Mayo Clinic (2007). Back surgery: When is it a good idea? [on-line]. Retrieved April 22, 2009. From http://mayoclinic.com/health/back-surgery/HQ00305.
American Physical Therapy Association (2009). The secret of good posture [on-line]. Retrieved April 22, 2009. From http://www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/
CM/HTMLDisplay.cfm&CONTENTID=20457.

Back Pain Prevention, reduction, management