On any given day, more than a million North Americans are confined to bed because of lower back pain. New cases of back pain occur at the rate of 1.5 million a month, and more than 200,000 North Americans have back surgery every year.
We’ll get to what we consider is the best way of treating the condition and why preventing back pain is better, but first, a little physiology.
The Perils of Being a Vertebrate
As you probably know, the word backbone is a misnomer; the correct term is spinal column: a structure composed of 33 vertebrae, most of which are separated by flexible cartilage disks. From top to bottom, there are seven cervical vertebrae in the neck, 12 thoracic vertebrae in the chest, and five lumbar vertebrae in the lower back; then five vertebrae fused together to form the sacrum , and four fused to form the coccyx or tailbone. The vertebral column supports the body and houses the spinal cord, encased in the spinal canal, a tunnel formed by holes in the vertebrae.
When our ancestors made that bold evolutionary gesture of standing up, they imposed tremendous stress on the vertebrae. Their backs became more susceptible to sliding out of alignment. The most vulnerable area is in the small of the back where the five lumbar vertebrae are located.
In front of the spinal canal is the vertebral body; behind it, each vertebra has four protruding bony processes that form joints with the adjoining vertebrae. The vertebrae are also connected by a network of muscles and ligaments, any of which may be strained and cause pain.
Between each vertebra and the next is an intervertebral disk, notorious for "slipping," which is something it does not actually do. The disk is a thin cartilage pad. Its center, the nucleus pulposus, is made of gelatinous material, 80% water, which cushions the vertebrae and makes the back elastic and flexible. Surrounding the nucleus pulposus is a harder fibrous ring, the annulus fibrosus. This is where serious back trouble usually starts. Accident, injury, or years of poor posture can weaken the annulus, and a rupture (hernia) can occur. A portion of the nucleus can protrude through the annulus. If the protruding portion of the nucleus presses against a nerve or ligament, the result is back pain. If the sciatic nerve, which runs down the leg, is affected, there may also be leg pain. Once a disk herniates, it's never quite the same. "The herniation," says San Francisco orthopedic surgeon Stanford Lazar, "can move back away from the nerve and the pain will resolve. But the disk does not return to normal. It's unstable, and can pop out again."
Number One: Rule Out Other Diseases
Today, most physicians encourage people with back problems to manage their conditions with exercise and self-care, but in the not-too-distant past they gravitated more toward drugs and surgery. Some still do. Unfortunately, neither drugs nor surgery is a particularly attractive option. At best, the former can provide temporary relief (usually with side effects). And the latter has only about a 50% success rate.
Still, there are plenty of reasons to take a back problem to a physician before seeking other therapies: The pain might be a symptom of some other illness — kidney disease, a tumor, bowel or bladder problems, gynecological problems in women, or prostate trouble in men. There might also be a congenital problem, such as lateral curvature of the spine (scoliosis), or abnormal front-to-back curvature of the spine (lordosis). After these possibilities have been ruled out, the way to heal a bad back is not to "fix it," but rather to stop hurting it.
Common Causes of Back Pain
Poor muscle tone. The spinal column is like a bridge connecting the upper and lower halves of our bodies. If the abdominal or lower back muscles or both are weak, the spine may shift from correct curvature to a shape that causes pain. Strengthening these muscles is the foundation of back self-care.
Poor posture. Good posture not only improves one's looks, but is essential to a pain-free back. Slouched standing and sitting can lead to problems. So can an overly arched spine.
Improper lifting. This is a frequent cause of traumatic back injury. Never lift anything by bending from the waist. Squat down, and with back straight, lift with the thigh muscles.
Sedentary lifestyle or poor home and office furniture. San Francisco orthopedic surgeon James Zucherman, a lumbar spine specialist, says that most back problems are caused by a disk herniating posterially, often caused by years and years of sitting without proper back support.
Overdoing exercise. Most fitness experts recommend stretching beforehand, though some say to start slowly and to stretch or do yoga afterwards. If your back starts hurting while you're exercising, stop whatever you're doing and rest, apply heat or massage, and do not resume any strenuous activity until the pain has subsided.
Improper clothing. Avoid restrictive clothing, especially high heels, which place tremendous strain on the back.
Weather. Damp cold can aggravate back problems. Try to keep warm and dry.
The Key: Exercise
"The most important element in dealing with back problems, and preventing them in the first place," Dr. Zucherman says, "is exercise designed to improve posture and to increase the strength and flexibility of the back and abdominal muscles. In fact, with good posture, proper exercises, and some common sense about sitting and lifting, most back problems could be prevented."
"Even with a disability like a bad back," says Meg Stern, a leader of back-care classes at Fitness for Living, in San Rafael, California, "the body has tremendous ability to change. Coming out of back pain is easy. Staying out is harder. It means working with breathing, learning body mechanics, and knowing how to move correctly when performing everyday tasks."
Dos and Don'ts
- Good posture means maintaining correct spinal alignment; it does not mean standing at military attention, however. When standing, walking, or running, try to tuck in your buttocks.
- Studies show that people working at desk jobs suffer herniated disks 60% more frequently than people who do not work at desks. If you work sitting down, the right chair is a must. Your knees should be as high as your hips. You want to sit on the two bones of the backside, rather than distributing your weight over soft tissue, which can cause numbing. Get out of your chair often.
- Be careful when sitting and rising. Don't heave yourself into or out of your chair. To stand, inch forward, straighten your back gradually, and use your hands to help you rise.
- Driving greatly increases risk of back problems. Truckers are at high risk for disk herniation, and those who alternate driving with loading and unloading are at even higher risk. While driving, a lumbar roll — a cylindrical pillow about four inches in diameter for the lower back — can be very useful.
- Sleep in a firm bed.
- Experiment with sleep positions. Many back experts recommend sleeping on your side in a fetal position. Some say sleeping on your back is bad because it doesn't support the lumbar spine. Others say sleeping on your front is bad because it exaggerates the arch in the back. Try all positions and see what works.
- Avoid bending forward. Lifting your own upper body can hurt the back.
- When lifting, in addition to using your thigh muscles, hold the object as close to your body as possible.
- Breathe deeply. The diaphragm muscle helps support the spine.
- Try to stay slim. Extra weight strains the back.
- If any physician recommends surgery, get several other opinions. Back surgery is an iffy proposition.
This issue's column was guest-written for Dr. Tom Ferguson by a contributor to Medical Self-Care magazine.