Back Pain

Overview

Postural muscles become short when stressed (overused, misused or abused) and require gentle, safe stretching methods as a rule (yoga type) to normalise them plus reeducation as to elimination of causes wherever possible. If strengthening is indicated isometric exercises are best. However when muscles become chronically shortened they will weaken their antagonists (so that tight low back muscles produce weak abdominals for example) and no strengthening of these weak muscles can occur until shortness and tightness has been effectively corrected. Imbalances such as this (hypertonic group inhibiting weak antagonist group) result in mal-coordination and functional problems, often preceding pathology such as disc herniation by many years. Chronically tight postural muscles affect tendinous structures and influence crowding of joint spaces in time.

Techniques Which Can Be Used When Pain is Present Include:
Rest, support, hydrotherapy (including ice), massage, exercise, manipulation, pain killing injections or medication, electrotherapy (including TENS), acupuncture, sclerosing injections for hypo-mobile structures, surgery. All may benefit from re-education employing stretching exercises, relaxation exercises, stress reducing measures etc.

What to Do When Your Back Is in Pain

By Carol Lewis

During his 27 years as a hospital corpsman, Richard Mettetal lifted injured people and remained suspended by harness from helicopters for long periods. For the 54-year-old Thurmont, Md., resident, the legacy of those years of public service is chronic back pain that has plagued him since 1984.

“It’s been so long now, I can’t remember when I didn’t feel the pain,” Mettetal says. “And I’m so angry that I can’t do all that I want because of it.”Work-related back pain is among the most common occupational disorders in the United States, according to the National Institute for Occupational Safety and Health in Cincinnati, Ohio. Delay in return to work remains an expensive component in the overall cost of back pain for workers’ compensation claims, as well, the institute notes. And back pain is responsible for more loss of work time and increased medical expenses related to treatment than any other ailment, says Robert Shields, M.D., an osteopathic physician practicing general medicine in Plano, Texas.”This is one of the most common problems I see in my medical practice,” he says. “Low back pain strikes 8 out of 10 adults at some point in their lives.”

Understanding Back Pain

Back pain comes in two forms, acute and chronic, and is most often felt in the lower back. Acute pain comes on suddenly and intensely, usually from doing something you shouldn’t be doing or from doing it in the wrong way. The pain usually lasts a short while. Chronic pain is recurring; any little movement can set it in motion and, for whatever reason, it lingers on and on for what can seem like an eternity.Although back pain is usually preventable (See “Back to Exercise” below), experts claim that 4 out of 5 Americans will experience it at some time in their lives, given that the lower back supports most of the body’s weight. The stability of the lower back depends on the integrity of the vertebral bodies and the intervertebral disks.To understand the many ways you can do injury to your back, consider that each of us has between 24 and 25 bones in and around our backs, including the neck and chest areas, which are held together by ligaments and muscles. Throw in some major nerves, a few disks (which act as shock absorbers), and joints that guide the direction of movement of the spine, and stack them all up, explains Shields. “Expect to twist and bend them in a multitude of directions, and try to imagine what might go wrong.”Shields says you can sprain the ligaments, strain the muscles, rupture the disks, and irritate the joints. While logic would point to injuries from sports or traumatic accidents as the cause of the pain, sometimes the simplest of movements will have painful results. In addition, arthritis, congenital disorders, poor posture, obesity, and psychological problems due to stress can be the source of back pain. Complicating the issue further is the fact that back pain can also directly result from internal problems such as kidney stones, kidney infections, blood clots, or bone loss.Even with modern technology, however, the exact reason or cause of back pain can be found in very few people, according to the Clinical Practice Guideline for “Understanding Acute Low Back Problems”, published in 1994 by the Department of Health and Human Services’ Agency for Health Care Policy and Research. X-ray examinations explain only a small proportion of the nonspecific complaints doctors receive.

Pain Management Options

Mettetal’s troubles began 14 years ago when he nearly collapsed from excruciating pain searing down his leg. His initial diagnosis was a ruptured disk. Since then, even with four major surgeries to repair the problems, his pain has only worsened. Out of desperation, he has tried medications, physical therapies, and pain clinics — all in an attempt to restore some semblance of a functional life.The Journal of the American Medical Association concluded in a 1996 surgical back pain study that more than $50 billion is spent on the diagnosis and treatment of back pain in the United States. Since the causes are so varied, what works for one person might fail with another.For most people, drugs work well to control pain and discomfort. But any medication can have side effects. Back pain experts say that over-the-counter, nonsteroidal anti-inflammatory drugs (NSAIDs) — including acetaminophen (Tylenol), naproxen (Aleve), and ibuprofen (Nuprin, Motrin IB and Advil) — can be of value in reducing the pain. More severe pain may require prescription medications such as oxycodone-release (Oxycontin), acetaminophen with codeine (Tylenol with Codeine), and meperidine (Demerol).Peter Rheinstein, M.D., director of the medicine staff in FDA’s Office of Health Affairs, says the many effective NSAIDs available on the market today means there is less need for narcotics. However, he cautions that all NSAIDs cause gastrointestinal bleeding, and advises that patients suffering from other medical conditions need to consult with their doctors about other treatment options for managing their back pain.”If you have an ulcer, for example, or are taking a blood thinner,” Rheinstein says, “you are at an increased risk for gastrointestinal bleeding and should have your doctor prescribe medication that won’t aggravate the ulcer or cause any kind of drug interaction.”

Exercise and Physical Therapy

Bed rest was once thought to be an effective treatment for back pain, but recently its therapeutic benefit has been questioned. In a study published in the 1996 issue of Spine, Finnish researchers experimented to find out whether exercises to mobilize the back worked better than bed rest. Subjects in the mobility test, who were encouraged to continue normal activities and have no daytime rest, appeared to have better back flexibility by the seventh day than their immobile counterparts, who remained in bed for the duration of the experiment.”Most people think that a week of bed rest will take away the pain,” says David Lehrman, M.D., chief of orthopedic surgery at St. Francis Hospital and founder of the Lehrman Back Center in Miami. “But that’s not so. For every week of bed rest, it takes two weeks to rehabilitate.”Vert Mooney, M.D., professor of orthopedic surgery at the University of California, San Diego School of Medicine, says that bed rest for low back pain should be limited to one day and exercise should begin immediately. He explains that exercises which increase flexibility and tone and strengthen muscles can get back pain sufferers up and around by hydrating disks that become painful from loss of fluid. “Exercise can actually pump fluid back into the disk,” Mooney says, “and it is important to keep the patient moving so that the disk remains fully hydrated.”However, FDA’s Rheinstein says, “For some people, bed rest is just the most comfortable position for the first couple of days.”Spinal manipulation, or osteopathic manipulative therapy and chiropractic, are therapies commonly practiced for correcting abnormalities that are thought to eventually cause disease and inhibit recovery. Shields uses this type of manual manipulation technique on the majority of his patients. Occasionally, however, the spasm is too great or the muscles are too traumatized — for example, following an automobile accident or a fall — and the pain or swelling must be “calmed down” using a muscle relaxer for a day or two before manipulation.

Surgical Procedures

Doctors recommend back surgery much less often now than in the past, and only for certain conditions that do not improve after other treatments have been tried. FDA has approved or cleared medical devices such as the Intervertebral Body Fusion device, Anterior Spinal Implant, and Posterior Spinal Implant to treat degenerative disk disease and stabilize and fuse the spine.Implantable spinal cord stimulation devices are another aid in the management of chronic pain of the trunk and limbs. These devices electrically stimulate the spinal cord by discharging a one-time or continuous stream of electrical pulses. The implanted portion of the device consists of a pulse generator (which contains an internal power source similar to that used in a cardiac pacemaker) and lead extensions that are connected to electrodes placed in the spinal canal. The nonimplanted components of the system include the programming device and screening pulse generator, which are controlled by the physician or patient.

Acupuncture

Acupuncture is a centuries-old Chinese healing technique that employs needles placed at specified points on the body. FDA classified acupuncture needles in 1996 as medical devices for “general use” by trained professionals.The needles are required to have proper labeling, and good manufacturing practices must be followed. Manufacturers must include on the label the statement “for single use only” and provide information about device material sterility and compatibility with the body. The needles must also bear a prescription label restricting use to qualified practitioners as determined by individual states.Harold Pellerite, assistant to the director of compliance in FDA’s Center for Devices and Radiological Health says, “I think today’s society is more receptive to alternative medicine. This just points to the need for our agency to be able to have some degree of control over what the American public is exposed to.”Complicating the evaluation of effectiveness of treatment is the fact that most back problems clear spontaneously. How can you tell if the problem was relieved by a particular treatment or if it would have gone away in the same period without treatment? “You really can’t,” says Shields.Out of all these options, only two things have given Mettetal any measure of relief — the Spinal Cord Stimulation System and acupuncture. But, as Shields points out, “One of the most important things to keep in mind is that pain is caused by a variety of underlying problems, and it is naive to think that one modality will help improve all back pain.”

Back to Exercise

Trying to move an immovable object is the number one cause of back problems in the United States. It encourages you to push, pull, twist, bend, lift, and strain the wrong way. Even an unexpected awkward turn can be the onset of low back pain, and people who are in poor physical condition or perform work that requires long periods of sitting or standing are at greater risk for back problems. These people also recover more slowly. And the more time you spend in front of the TV or computer, the more you must do to prevent back pain, say experts. Emotional stress or long periods of inactivity may make back symptoms seem worse, but good posture and body mechanics will ultimately reduce the stress on your back.To reduce the incidence of self-inflicted back problems:

• Be careful. Learn to lift and lean properly. Avoid positions that cause sudden, quick or jerky movements.
• Exercise. Strengthening the muscles of the back and abdomen helps to minimize the frequency, and possibly the severity, of future incidents.
• Lose weight. If you are more than 10 percent over your ideal body weight, you can reduce further incidents by losing weight through dietary restriction of calories and aerobic exercise, as prescribed by your personal physician.

— C.L.

Carol Lewis is a writer in FDA’s Office of Consumer Affairs.

Lower-Back Exercises

A. Lie flat on your back. Hug your knees to your chest and at the same time, bring your chin to your chest. Repeat twice, holding for 15 seconds each.B. Begin on your hands and knees. Simultaneously raise and straighten your right arm and left leg until they are parallel to the ground. Hold for 2 seconds and come back slowly to a starting position. Repeat with left arm and right leg, alternating 10 times.C. Lie facedown, arms extended overhead, palms on floor. Simultaneously raise your right arm and left leg as high as comfortably possible. Hold for 10 seconds and slowly return to start. Repeat with left arm and right leg, alternating 10 times. Gradually build up to 20 times.D. Lie facedown, arms at your side and place heels under couch. Slowly raise chest off the floor as high as you comfortably can. Hold for 2 seconds and return to start. Gradually increase to 20 times.Strong lower-back muscles and abdominals work together in maintaining a pain-free and healthy back. These exercises will help strengthen the muscles of the lower back, but it is important that you begin your exercises slowly and increase levels gradually. Always begin any exercise program with stretching. Talk to your doctor before attempting any exercises, especially if you are already experiencing back pain.