Back pain

Definition

Back pain is a common complaint. Most people in the United States will experience low back pain at least once during their lives. Back pain is one of the most common reasons people go to the doctor or miss work.

On the bright side, you can take measures to prevent or lessen most back pain episodes. If prevention fails, simple home treatment and proper body mechanics will often heal your back within a few weeks and keep it functional for the long haul. Surgery is rarely needed to treat back pain.

Symptoms

Symptoms of back pain may include:

  • Muscle ache
  • Shooting or stabbing pain
  • Pain that radiates down your leg
  • Limited flexibility or range of motion of your back
  • Inability to stand straight

Back pain that lasts from a few days to a few weeks is considered acute. Pain that lasts for three months or longer is considered chronic.

When to see a doctor Most back pain gradually improves with home treatment and self-care. Although the pain may take several weeks to disappear completely, you should notice some improvement within the first 72 hours of self-care. If not, see your doctor.

In rare cases, back pain can signal a serious medical problem. Contact a doctor if your back pain:

  • Is constant or intense, especially at night or when you lie down
  • Spreads down one or both legs, especially if the pain extends below your knee
  • Causes weakness, numbness or tingling in one or both legs
  • Causes new bowel or bladder problems
  • Is associated with pain or throbbing (pulsation) in your abdomen, or fever
  • Follows a fall, blow to your back or other injury
  • Is accompanied by unexplained weight loss

Also, see your doctor if you start having back pain for the first time after age 50, or if you have a history of cancer, osteoporosis, steroid use, or drug or alcohol abuse.

Causes

Your back is an intricate structure composed of bones, muscles, ligaments, tendons and disks. Disks are 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.

Strains Back pain most often occurs:

  • From strained muscles and ligaments
  • From improper or heavy lifting
  • After a sudden awkward movement

Sometimes a muscle spasm can cause or be associated with back pain.

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

  • Bulging or ruptured disks. Disks act as cushions between the vertebrae in your spine. Sometimes, the soft material inside a disk may bulge out of place or rupture and press on a nerve. But even so, many people who have bulging or herniated disks experience no pain from the condition.
  • Sciatica. If a bulging or herniated disk presses on the main nerve that travels down your leg, it can cause sciatica — sharp, shooting pain through the buttock and back of the leg.
  • Arthritis. The joints most commonly affected by osteoarthritis are the hips, hands, knees and lower back. In some cases arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
  • Skeletal irregularities. Back pain can occur if your spine curves in an abnormal way. If the natural curves in your spine become exaggerated, your upper back may look abnormally rounded or your lower back may arch excessively. Scoliosis, a condition in which your spine curves to the side, also may lead to back pain.
  • Osteoporosis. Compression fractures of your spine's vertebrae can occur if your bones become porous and brittle.

Rare but serious conditions In rare cases, back pain may be related to:

  • Cauda equina syndrome. This is a serious neurological problem affecting a bundle of nerve roots that serve your lower back and legs. It can cause weakness in the legs, numbness in the "saddle" or groin area, and loss of bowel or bladder control.
  • Cancer in the spine. A tumor on the spine can press on a nerve, causing back pain.
  • Infection of the spine. If a fever and a tender, warm area accompany back pain, the cause could be an infection.

Risk factors

Factors that increase your risk of developing low back pain include:

  • Smoking
  • Obesity
  • Older age
  • Being female
  • Physically strenuous work
  • Sedentary work
  • Stressful job
  • Anxiety
  • Depression

Appointment

If you have back pain that's lasted for at least a few days and isn't improving, make an appointment with your family doctor or primary care provider.

Here's some information to help you prepare for your appointment and what to expect from your doctor.

What you can do

  • Write down any symptoms you've been having, and for how long.
  • Write down key personal information, including any mental or emotional stressors in your life.
  • Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
  • Note any recent injuries that may have damaged your back.
  • Take a family member or friend along, if possible. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.

For back pain, some basic questions to ask your doctor include:

  • What is the most likely cause of my back pain?
  • Are there any other possible causes?
  • Do I need any diagnostic tests?
  • What treatment approach do you recommend?
  • If you're recommending medications, what are the possible side effects?
  • For how long will I need to be treated?
  • Are there any restrictions that I need to follow?
  • What other self-care measures should I be taking?
  • Is there anything else I can do to help prevent a recurrence of back pain?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

  • When did you first begin having back pain?
  • How often do you have back pain?
  • What do you think is causing your pain?
  • How much is your pain limiting your ability to function?
  • Do you have any other signs or symptoms in addition to back pain?
  • Do you have leg pain associated with your back pain?
  • Have you had any unexplained fevers or weight loss?
  • Does your work or recreational activities involve any heavy physical work?
  • Do you exercise regularly? If yes, with what types of activities?
  • How often do you feel blue or depressed?
  • How much stress or conflict do you experience on a daily basis?
  • Do you sleep well most of the time?
  • Do you smoke?
  • Do you use recreational drugs?
  • What treatments or self-care measures have you tried so far? Has anything helped?
  • Are you currently being treated or have you recently been treated for any other medical conditions?
  • What medications are you currently taking, including prescription and over-the-counter drugs as well as vitamins and supplements?

What you can do in the meantime While you're waiting for your appointment, you may find some relief by using over-the-counter pain relievers, such as aspirin, ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others). You may also benefit from applying heat and cold to the area that's causing you pain.

Tests and diagnosis

Diagnostic tests aren't usually necessary to confirm the cause of your back pain. However, if you do see your doctor for back pain, he or she will:

  • Examine your back and assess your ability to sit, stand, walk and lift your legs
  • May also test your reflexes with a rubber reflex hammer

These assessments help determine where the pain comes from, how much you can move before pain forces you to stop and whether you have muscle spasms. They will also help rule out more serious causes of back pain.

If there is reason to suspect that you have a tumor, fracture, infection or other specific condition that may be causing your back pain, your doctor may order one or more tests:

  • Blood and urine tests. Your doctor may order these lab tests to determine whether an underlying disease or infection may be contributing to your back pain.
  • X-ray. These images show the alignment of your bones and whether you have arthritis or broken bones. X-ray images won't directly show problems with your spinal cord, muscles, nerves or disks.
  • Magnetic resonance imaging (MRI) or computerized tomography (CT) scans. These scans can generate images that may reveal herniated disks or problems with bones, muscles, tissue, tendons, nerves, ligaments and blood vessels.
  • Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis. In this procedure, you'll receive an injection of a small amount of a radioactive substance (tracer) into one of your veins. The substance collects in your bones and allows your doctor to detect bone problems using a special camera.
  • Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. Studies of your nerve-conduction pathways can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).

Treatments and drugs

Most back pain gets better with a few weeks of home treatment and careful attention. A regular schedule of over-the-counter pain relievers may be all that you need to improve your pain. A short period of bed rest is OK, but more than a couple of days actually does more harm than good. If home treatments aren't working, your doctor may suggest stronger medications or other therapy.

Medications Your doctor is likely to recommend pain relievers such as acetaminophen (Tylenol, others) or nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil, Motrin, others) or naproxen (Aleve, others). If mild to moderate back pain doesn't get better with over-the-counter pain relievers, your doctor may also prescribe a muscle relaxant.

Narcotics, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.

Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve chronic back pain, independent of their effect on depression.

Physical therapy and exercise A physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques will help prevent pain from returning.

Injections If other measures don't relieve your pain and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than a few months.

In some cases, your doctor may inject numbing medication and cortisone into or near the structures believed to be causing your back pain, such as the facet joints of the vertebrae. Located on the sides, top and bottom of each vertebra, these joints connect the vertebrae to one another and stabilize the spine while still allowing flexibility.

Surgery Few people ever need surgery for back pain. If you have unrelenting pain associated with radiating leg pain or progressive muscle weakness caused by nerve compression, you may benefit from surgical intervention. Otherwise, surgery usually is reserved for pain related to structural anatomical problems that haven't responded to intensive conservative therapy measures.

Types of back surgery include:

  • Fusion. This surgery involves joining two vertebrae to eliminate painful movement. A bone graft is inserted between the two vertebrae, which may then be splinted together with metal plates, screws or cages. A drawback to the procedure is that it increases the chances of arthritis developing in adjoining vertebrae.
  • Partial removal of disk. If disk material is pressing or squeezing a nerve, your doctor may be able to remove just the portion of the disk that's causing the problem.
  • Partial removal of a vertebra. If your spine has developed bony growths that are pinching your spinal cord or nerves, surgeons can remove a small section of the offending vertebra, to open up the passage.

Alternative medicine

A number of alternative treatments are available that may help ease symptoms of back pain. Always discuss the benefits and risks with your doctor before starting any new alternative therapy.

Herbal treatments Some herbal supplements with anti-inflammatory properties may ease back pain. Although more research is needed to reliably determine their safety and efficacy, some studies suggest that the following herbs may be helpful:

  • Willow bark (Salix alba), taken orally
  • Devil's claw (Harpagophytum procumbens), taken orally
  • Capsicum (Capsicum frutescens), applied as a topical plaster

Hands-on therapies

  • Chiropractic care. Back pain is one of the most common reasons that people see a chiropractor. If you're considering chiropractic care, talk to your doctor about the most appropriate specialist for your type of problem. In addition to chiropractors, many osteopathic doctors and some physical therapists have training in spinal manipulation.
  • Acupuncture. Some people with low back pain report that acupuncture helps relieve their symptoms. The National Institutes of Health has found that acupuncture can be an effective treatment for some types of chronic pain. In acupuncture, the practitioner inserts sterilized stainless steel needles into the skin at specific points on the body.
  • Massage. If your back pain is caused by tense or overworked muscles, massage therapy may help loosen knotted muscles and promote relaxation.

Mind-body techniques

  • Cognitive behavioral therapy. Chronic back pain is commonly associated with emotional stress and mental health conditions, such as depression. In cognitive behavioral therapy, you learn to identify and change negative thought patterns that have a damaging impact on your mental and physical health. Research has found that this type of therapy may significantly relieve chronic low back pain.
  • Progressive relaxation. This relaxation technique involves systematically tensing and relaxing different muscle groups in your body. Progressive muscle relaxation boosts your ability to recognize and counteract muscle tension as soon as it starts. Evidence suggests this technique helps ease back pain.

In addition, a type of yoga called Viniyoga — which emphasizes both postures and breathing exercises — may help ease back pain and reduce the need for pain medications.

Prevention

You may be able to avoid back pain by improving your physical condition and learning and practicing proper body mechanics.

To keep your back healthy and strong:

  • Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.
  • Build muscle strength and flexibility. Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels.
  • Quit smoking. Smokers have diminished oxygen levels in their spinal tissues, which can hinder the healing process.
  • Maintain a healthy weight. Being overweight puts strain on your back muscles. If you're overweight, trimming down can prevent back pain.

Use proper body mechanics:

  • Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.
  • Sit smart. Choose a seat with good lower back support, arm rests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.
  • Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.

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