Pain and Sciatica
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WHAT ARE LOW BACK PAIN AND SCIATICA?
The spine is a column of small bones, or vertebrae, that
support the entire upper body. The column is grouped into three
sections of vertebrae:
can be designated by using a letter and number; the letter reflects
the region (C=cervical, T=thoracic, and L=lumbar) and the number
signifies its location within that region. For example, C4 is the
fourth bone down in the cervical region and T8 is the eighth thoracic
- The cervical
(C) vertebrae are the seven spinal bones that support the neck.
- The thoracic
(T) vertebrae are the twelve spinal bones that connect to the
- The lumbar
(L) vertebrae are the five lowest and largest bones of the spinal
column. Most of the body's weight and stress falls on the lumbar
the lumbar region is the sacrum, a shield-shaped bony
structure that connects with the pelvis at the sacroiliac joints.
- At the
end of the sacrum are two to four tiny, partially fused vertebrae
known as the coccyx or "tail bone."
The Discs. Vertebrae in the spinal column are separated
from each other by small cushions of cartilage known as intervertebral
discs . Inside each disc is a jelly-like substance called the
nucleus pulposus , which is surrounded by a tough, fibrous
shell called the annulus. The disc is 80% water. This structure
makes the disk both elastic and strong. The discs have no blood
supply of their own, however, but rely on nearby blood vessels to
keep them nourished.
Processes. Each vertebra in the spine has a number of bony
projections, known as processes. The spinal and transverse
processes attach to the muscles in the back and act like little
levers, allowing the spine to twist or bend. The particular processes
form the joints between the vertebrae themselves, meeting together
and interlocking at the facet joints .
Spinal Canal. Each vertebra and its processes surround and
protect an arch-shaped central opening. These arches, aligned to
run down the spine, form the spinal canal, which encloses the spinal
Spinal Cord. The spinal cord is the central trunk of nerves
that connects the brain with the rest of the body. Each nerve root
passes from the spinal column to other parts of the body through
small openings bounded on one side by the disc and the other by
the facets. When the spinal cord reaches the lumbar region, it splits
into four bundled strands of nerve roots called the cauda equina
(meaning horsetail in Latin).
The Sciatic Nerve. The sciatic nerve is the one most likely
to be affected in low back pain and has an extensive pathway:
Each then passes
down the hip and along the back of the thigh to the foot.
- It first
branches from the nerve roots that descend off the lowest part
of the spinal cord (in the lumbar and sacral areas). Each of
the two branches of the sciatic nerve is about as wide as a
- Each threads
through the pelvis and deep into either side of the buttocks.
Low back pain
is usually defined as either acute or chronic.
The source of
low back pain can be from abnormalities in one or more of the many
structures in the spine:
low back pain lasts less than a month and is not caused by serious
medical conditions. Most cases clear up in a few days without
medical attention, although recurrence after a first attack
low back pain persists beyond six months. It constitutes only
1% to 5% of all low back pain cases.
and small fractures can occur.
spasms can cause pain.
on a weakened disc may cause it to rupture so the nucleus pulposus
protrudes out from the spinal column, a condition known as a
herniated disc .
- The facets
can become misaligned or deteriorate.
- The spinal
canal itself can become narrowed, a disorder called spinal
- Scar tissue
in the lower spine can trap nerves.
At some time,
up to 40% of people experience pain, known as sciatica,
which occurs when the sciatic nerve is trapped or inflamed.
Causes of Sciatica. A herniated disc pressing on the sciatic
nerve is the most common cause of this problem, although spinal
stenosis or other vertebral abnormalities that press on the sciatic
nerve can also cause pain. [ See What Causes the Pain in
Low Back Pain or Sciatica?.]
Symptoms of Sciatica. Symptoms of sciatica involve the following:
- The sensation
of sciatica is usually experienced along the course of the sciatic
nerve, which travels from the lower back, through the buttock,
into the calf, and sometimes even the foot.
- The pain
can vary widely, from a mild tingling to pain, to a dull ache,
to a burning sensation, to pain severe enough to cause immobility.
- It most
often occurs on one side. Some people experience sharp pain
in one part of the leg or hip and numbness in other parts. The
affected leg may feel weak.
- The pain
often starts slowly and typically worsens at night.
- The pain
increases after prolonged standing or sitting.
- It is
often aggravated by sneezing, coughing, or laughing.
may also experience it after bending backwards or walking more
than 50 to 100 yards, particularly if it is caused by spinal
- The pain
usually resolves within six weeks with mild activity.
CAUSES THE PAIN IN LOW BACK PAIN OR SCIATICA?
In about 85%
of back pain cases, the origin of the pain is unknown and even imaging
studies usually fail to determine the cause.
Disc and Other Disc Abnormalities
and disc degeneration due to aging are the most common causes of
low back pain. Other problems can also cause this pain, however.
Lumbar Degenerative Disc Disease. Over the years, the disc
can degenerate and produce low-grade inflammation and irritation.
This age-related condition is the major source of chronic low back
Herniated Disc. A herniated disc, sometimes, but incorrectly,
called a slipped disc, is widely held to be the most common cause
of severe back pain and sciatica. A disc in the lumbar area becomes
herniated when it ruptures or thins out and degenerates to the point
that the gelatin within the disc protrudes outward.
It is commonly believed that that low back pain most often occurs
if this material extrudes (that is, it balloons into the
area outside the vertebrae or breaks off from the disc) far enough
out to press against the nerve root, most often the sciatic nerve.
Recently, however, researchers are finding that the presence of
such a pinched nerve does not necessarily relate to the severity
of the pain. In fact, as people age, disc bulging and protrusion
are very common occurrences, and in most cases do not cause any
back pain. And, sciatica pain is sometimes present when there is
no bulging or extruding of the discs. Experts increasingly believe,
then, that low back pain associated with disc abnormalities may
result from factors other then compressed nerves.
The Annular Ring. Increasingly, research is focusing on
tears in the annular ring, which is the fibrous band that surrounds
and protects the disc. The annular ring contains a dense nerve network
and high levels of peptides that heighten perception of pain:
in the annular ring are a frequent finding in patients with
degenerative disk disease.
cases of chronic low back pain may be caused by inward growth
of nerve fibers into the annular ring, which trigger pain within
and Ligament Injuries
Other than age-related
degenerative disk disorders injuries in the muscles and ligaments
supporting the back are the major causes of low back pain.
is the narrowing of the spinal canal. This typically develops as
a person ages and the discs become drier and start to shrink. At
some point in this process, any disruption, such as a minor injury
that results in disc inflammation, can cause impingement on the
nerve root and trigger pain. Pain from spinal stenosis can occur
in both legs or can cause sciatic pain. Spinal stenosis occurs mostly
in the elderly with degenerative osteoarthritis, but it can sometimes
be caused by other problems, including infection and birth defects.
A number of conditions
that affect the joints, vertebrae, or nerve roots can cause back
is a condition in which one vertebra has slipped forward over
the other. This is also a cause of sciatica.
- The facet
joints can wear down. In such cases, pain occurs on arching
the back or when walking.
- In some
cases a segment (consisting of two vertebra and their common
joint and disc) becomes unstable when its parts wear down.
- Some patients
may have scar tissue that traps the nerve roots in the lower
spine and causes sciatica.
believe that one cause of sciatica pain is the entrapment of the
sciatic nerve deep in the buttock by the piriformis muscle.
It usually develops after an injury. Others believe there is no
real evidence that this condition, known as piriformis syndrome,
causes any sciatic pain.
CONDITIONS MAKE PEOPLE SUSCEPTIBLE TO LOW BACK PAIN?
In most known
cases, pain begins with an injury, after lifting a heavy object,
or after making an abrupt movement. A number of conditions may make
people more or less susceptible to low back pain from such events.
In 85% of back pain cases, the causes are unknown.
discs begin deteriorating and growing thinner by age 30. One-third
of adults over 20 show evidence of herniated discs (although only
3% of these discs cause symptoms). As people continue to age and
the discs lose moisture and shrink, the risk for spinal stenosis
increases. The incidence of low back pain and sciatica increases
in women at the time of menopause as they lose bone density. In
the older adults, osteoporosis and osteoarthritis are also common.
However, the risk for low back pain does not mount steadily with
ever-increasing age, which suggests that at a certain point, the
conditions causing low back pain plateau.
Spinal Structure Abnormalities. Many people have a genetic
susceptibility to low back pain, usually from inheriting spinal
Abnormalities in Disk Strength. Studies are finding that
specific mutations of the COL9A gene may play a role in about 10%
of sciatica cases. The gene is normally involved in producing collagen,
the protein building block in all structural tissue in the body.
When defective, it may cause the disk to be less able to resist
compressive forces. One 2001 study found the defective gene was
present in twice as many patients with disk problems as in patients
without back pain.
Central Nervous System Abnormalities
After episodes of back pain, some people may experience changes
in brain function that lead them to experience chronic back pain.
Such changes include an exaggerated response in nerve cells or other
factors that cause a persistent perception of pain even without
an actual physical injury.
occurs in joints where cartilage is damaged and then destroyed.
In reaction to this destruction, the bones associated with the joints
develop abnormalities. (Rheumatoid arthritis, which is an arthritic
condition caused by inflammation in the joints, can damage joints
throughout the body, but rarely affects the lower back.) When osteoarthritis
affects the spine, it may damage the cartilage in the discs, the
moving joints of the spine, or both. The nerves may become pinched,
causing pain and in advanced cases, numbness and muscle weakness.
The patient may also experience muscle spasms and diminished mobility.
and Social Factors
factors are known to play a strong influential role in three phases
of low back pain:
It should be
strongly noted that the presence of psychological factors in no
way diminishes the reality of the pain and its disabling effects.
Recognizing it as a strong player in many cases of low back pain,
however, can help determine the full range of treatment options.
of pain. Although disc abnormalities are certainly a cause
of low back pain, many people with disc rupture or tears do
not experience back pain. And some people without disc abnormalities
complain of back pain. Research now indicates that in many people,
preexisting depression and the inability to cope may be more
likely to predict the onset of pain than physical abnormalities.
perception of pain. Social and psychologic factors play
a role in how severely someone experiences pain. People who
are depressed are more likely to have vague physical symptoms,
including low back pain. For example, in one study of truck
drivers and bus drivers, nearly all the truck drivers liked
their work and their bosses while bus drivers reported much
lower job satisfaction. Half the truck drivers reported low
back pain but only 24% lost time at work. Bus drivers with back
pain had a significantly higher absentee rate in spite of less
stress on their backs. Similarly, another study found that pilots
(who generally reported "loving" their jobs) reported far fewer
back problems than their flight crews. And yet another study
reported that low rank, low social support, and high stress
in soldiers was associated with a higher risk for disabling
pain. The way a patient perceives and copes with pain at
the beginning of an acute attack may actually condition the
patient to either recover or develop a chronic condition. Those
who over-respond to pain tend to feel out of control and become
discouraged, increasing their risk for long-term problems. One
study, in fact, reported that in patients with existing back
problems, the fear of pain was actually more disabling than
the pain itself.
are prone to back pain due to a shifting of abdominal organs, the
forward redistribution of body weight, and the loosening of ligaments
in the pelvic area as the body prepares for delivery. Tall people
are at higher risk than short people.
is a disease of the skeleton in which the amount of calcium present
in the bones slowly decreases to the point where the bones become
fragile and prone to fracture. It usually does not cause pain unless
the vertebrae collapse suddenly, when pain is often severe. Studies
indicate, however, that the incidence of low back pain and sciatica
increase around the time of menopause, and very tiny fractures in
the vertebrae caused by osteoporosis may be an undetected cause
of back pain in many elderly women.
a common cause of back pain. Osteomyelitis is infection in the spine,
a rare cause of back pain. Other infections that cause back pain
include Lyme disease, septic arthritis, bacterial endocarditis,
Reiter's syndrome, mycobacterial and fungal arthritis, and viral
arthritis. Chronic uterine or pelvic infections can cause low back
pain in women.
(commonly called hardening of the arteries) reduces blood supply
in the arteries. Although mainly known as a cause of heart disease,
atherosclerosis can also reduce the supply of blood to the back
and cause chronic low back pain. When it blocks arteries in the
legs (a condition called intermittent claudication) it may resemble
is a chronic inflammation of the spine that may gradually result
in a fusion of the spine. Symptoms include a slow development of
back discomfort, with pain lasting for more than three months. The
back is usually stiff in the morning; pain improves with exercise.
In severe cases, the patient must continually stoop over. It can
be quite mild, however, and it rarely affects a person's ability
to work. It occurs mostly in young Caucasians in their mid-twenties.
The disease is more common in men, but about 30% of the cases are
in women. Researchers believe that in most cases it is hereditary.
About 20% of people with inflammatory bowel disease and about 20%
of people with psoriasis develop a form of ankylosing spondylitis.
is suggesting that some people have motor control abnormalities
in the deep muscles near the spine. Such lack of control causes
instability in the spine that can lead to pain.
pain can be caused by problems in other organs, usually near the
spine, which is then called referred pain. These conditions can
include ulcers, kidney disease (including kidney stones), ovarian
cysts, and pancreatitis. Inflammatory bowel disease and rheumatoid
arthritis can produce inflammation in the spine ( sacroiliitis).
Back pain can also be due to abscesses, blood clots, and cancer.
Fibromyalgia (also called fibrositis or fibromyositis) is a syndrome
that causes chronic, sometimes debilitating muscle pain and fatigue.
In older people, low back pain may be a sign of Paget's disease
or Parkinson's. [For more information see the
trigger back pain. For example, anticoagulants can cause bleeding
or an internal bruise. Long-term steroid use can cause infection
or compression fractures.
that Cause Back Pain in Children
back pain in children is more likely to have a serious cause that
requires treatment than back pain in adults. According to one small
study, one third of children being treated at a hospital for back
pain were found to have serious underlying problems. Among the conditions
that cause back pain in children are the following:
are stress fractures in the spine. They are a common cause of
back pain in young athletes. (Sometimes a fracture may not show
up for a week or two after an injury.)
is an inborn exaggerated inward curve in the lumbar area. (Scoliosis,
an abnormal curvature of the spine in children, does not usually
cause back pain.)
tumors (eg, osteoblastoma or neurofibroma).
chronic arthropathy. This is an inherited form of arthritis
that can cause pain in the sacrum and hip joints of children
and young people. It used to be grouped under juvenile rheumatoid
arthritis but is now defined as a separate problem.
ARE THE LIFESTYLE RISK FACTORS FOR LOW BACK PAIN?
Between 60% and
90% of the population experience back pain at one time or another
during their lifetimes. Every year, nearly 15% of American adults
visit their doctors because of low back pain episodes. Men and women
are equally at risk. Low back pain is second only to upper respiratory
infections (such as colds and flus) as the reason for seeing a doctor.
In its costs to the country, it is second only to cancer and heart
In one study,
16 out of 100 warehouse workers reported back injuries in one year,
and in two major food service organizations 30% of all injuries
involved the back. A major study of work-related injuries reported
that, in 1994, there were nearly 330,000 cases of back injury due
to overexertion in handling objects.
Jobs that involve lifting and forceful movements, bending and twisting
into awkward positions, and whole-body vibration (usually caused
by long-distance truck driving) place workers at particular risk
for low back pain. The longer a person is on such jobs, the higher
the risk. Some workers wear back support belts, but evidence strongly
suggests that they are useful only for people who are currently
suffering from low back pain. They offer little added support for
the back and do not prevent back injuries. In fact, in one study
workers who wore the belt for prevention reported more back pain
than the workers who didn't wear them.
A number of companies are developing programs to protect against
back injuries. Although studies are mixed on the effects of company
interventions, one analysis suggested that they do have a positive
effect. Employers and workers, however, should make every effort
to create a safe working environment. Office workers should have
chairs, desks, and equipment that support the back or help maintain
or Intense Exercise
On the other
side of the coin, improper or excessive exercise is also an important
risk factor for back pain.
- The effect
of high-impact exercise on the back is not entirely clear. Some
research suggests that over time, it may increase the risk for
degenerative disc disease. A survey of people who played tennis,
however, found no increased risk for low back pain or sciatica.
30% and 70% of cyclists experience low back pain. (One 1999
study reported that 70% of cyclists reported improvement simply
by adjusting the angle of the bicycle seat.)
exercise instruction and inattention to mechanics can be sources
of sudden trouble. As examples, a single jerky golf swing or
incorrect use of exercise equipment (especially free weights,
nautilus, and rowing machines) can cause serious back injuries.
People who do
not exercise regularly face an increased risk for low back pain,
especially during times when they suddenly embark on stressful unaccustomed
activity, such as shoveling, digging, or moving heavy items. Although
no definitive studies have been done to prove the relationship between
lack of exercise and low back pain, sedentary living is probably
a primary nonmedical culprit contributing to this condition. Lack
of exercise leads to the following conditions that may threaten
inflexibility (can restrict the back's ability to move, rotate,
- Weak stomach
muscles (can increase the strain on the back and can cause an
abnormal tilt of the pelvis).
- Weak back
muscles (may increase the load on the spine and the risk for
associated with sedentary lifestyle (may put more weight on
the spine and increase pressure on the vertebrae and discs).
Studies report only a weak association between obesity and low
back pain, however.
Factors for Back Pain in Children and Adolescents
of experiencing back pain increases as children age, and pain is
more common among girls than boys, according to a 1999 study. A
common cause of temporary back pain is carrying backpacks that are
too heavy for children (more than 20% of their body weight, or even
less for very young children).
Smokers are at
higher risk for back problems, perhaps because smoking decreases
blood circulation, but the association may also be due to an unhealthy
lifestyle in general.
SERIOUS IS LOW BACK PAIN OR SCIATICA?
Uncomplicated Low Back Pain
Studies now suggest that more patients have chronic back pain than
previously believed. About a third of patients with uncomplicated
low back pain are significantly improved after a week and two thirds
have recovered by seven weeks. Within six months, however, some
research suggests that 40% of patients experience another bout of
back pain. In another survey, over a one-year period following treatment
only 21% of patients had no recurring back pain. Over four years,
less than half were symptom-free. Some physicians are approaching
the problem as they would any chronic illness, one that is not necessarily
curable and that needs a consistent on-going approach.
Specific conditions can determine the rate of improvement:
- In the
majority of patients with herniated disks, the condition improves
(although the actual physical improvement may be slower than
the reduction in pain.) Researchers attempted to identify factors
most likely to predict an elevated risk for recurrent pain and
found that only depression was a significant factor in the majority
of those who had not recovered.
stenosis stabilizes in about 70% of cases and worsens in 15%.
Only about 15% of these patients improve.
found that when people stay home because of back injury, only 65%
are back within a week and nearly 14% are still absent at one month.
And, if someone is on disability for more than six months, the person
has only a 50% chance of returning to work.
Low back pain accounts for significant losses in work days and dollars.
In 1990, it cost the US $23 billion in direct medical costs and
possibly as much as $85 billion in total costs (such as lost productivity.
Chronic back pain has become one of the most expensive causes of
disability among workers under the age of 45. One study found that
although severe back pain comprised only 10% of workers compensation
cases it accounted for 86% of compensation costs.
syndrome is the impingement of the cauda equina (the four strands
of nerves leading through the lowest part of the spine) and can
have severe complications in the bowel or bladder. It is an emergency
condition. It is usually caused by massive extrusion of the disc
material. Cauda equina syndrome can cause permanent incontinence
if not promptly treated with surgery. Symptoms of the syndrome include
- Dull back
or numbness in buttocks, genital area, or thigh.
- An inability
to control urination or defecation. Pain accompanied by fever
can indicate an infection.
Signs for Serious Underlying Problems
signs should alert a patient to see a physician immediately for
low back pain. Any very severe back pain warrants attention, particularly
if any of the following conditions are present:
- Pain awakens
the person at night.
- Pain accompanied
by fever (possible infection).
- Pain increased
by lying down.
- Pain unrelated
- Pain lasts
for a month, and is accompanied by unexplained fever or weight
loss. (Possible indication of a tumor particularly in people
with a history of cancer).
or chronic use of corticosteroids.
of urinary tract infection.
- In children,
any severe neck or back pain or pain that persists for more
than three days.
IS LOW BACK PAIN OR SCIATICA DIAGNOSED?
all cases of low back pain clear up in a short time and are not
due to serious problems, a medical history and a brief physical
examination are almost always sufficient. If the physician suspects
a serious underlying cause, the approach to determining the origin
of back pain involves answering three questions:
can usually be answered with a medical history and physical examination.
- Is some
general medical disorder present that could be causing the pain?
- Are there
social or emotional factors that might be intensifying the pain?
- Are the
nerves in the spine involved in the pain (such as in sciatica)?
A medical and
family history should include heart problems, cancer, arthritis,
and any other serious conditions. The patient should report the
episodes of back pain.
- Any history
of injuries or accidents involving the neck, back, or hips.
- Any indications
of a serious underlying disease (eg, history of cancer, unexplained
weight loss, chronic infection).
- The frequency,
duration, and the nature of the pain (eg, whether it is dull,
piercing, throbbing, or burning).
- The timing
of back pain (whether it occurs at night or during the day).
surrounding the onset and whether the pain was triggered by
an event, such as lifting a heavy object. (Often, the patient
cannot describe an event that produced the pain.)
- Any condition
that worsens the pain (for example, coughing, exercise, straining
during bowel movements, walking).
- Any situation
that relieves the pain (lying down, exercise).
with urination or defecation (symptom of cauda equina syndrome).
relevant symptoms (eg, morning stiffness, weakness or numbness
in the legs).
The main objectives
of a physical examination are to attempt to locate the specific
location of the pain source and to determine limits of movement:
are asked to sit, stand, and walk in different ways (flat-footed,
on the toes, and on their heels).
- In some
cases they are asked to walk on a treadmill to test for weakness
in toe or heel walking (which may indicate stenosis).
will be requested to bend forward, backward, and sideways and
will be asked to lift their leg straight up while lying down.
The physician will also move the patient's legs in different
positions and bend and straighten the knees. (Pain caused by
sciatica can be intensified by lifting the affected leg straight
in the air. It is usually sharp, localized, and accompanied
by numbness or tingling. Pain caused by inflammation is duller
and more generalized and not affected by lifting a straight
- The physician
may measure the circumference of the calves and thighs to look
for muscle deterioration.
- To test
nerve function and reflexes, physicians will tap the knees and
ankles with a rubber hammer. The physician may also touch parts
of the body lightly with a pin, cotton swab, or feather to test
for numbness and nerve sensitivity.
such as x-rays or scans are rarely useful except under certain circumstances
that may include the following:
If these conditions
exist, usually an x-ray is used first. If results are inconclusive,
either computed tomography (CT) or magnetic resonance imaging (MRI)
may be performed. (Ultrasound is not useful.)
- Pain that
lasts more than a month.
- Very severe
- A previous
accident or injury that might have affected the back.
- A history
of cancer or other indications of an underlying disease, such
as fever or unexplained weight loss.
- In older
patients (over 65 years of age).
CT and MRI
Scans. Computed tomography (CT) or magnetic resonance imaging
(MRI) are not painful and can identify disc abnormalities. MRIs
are more accurate than CTs and provide very well-defined images
of soft tissue and bone. MRIs are able to detect annular tears or
disc fragments and can detect non-spinal causes of back pain, including
infection and cancer. They are expensive, however, and many experts
believe they are overused and, in most cases of back pain, are not
very useful. Reasons are as follows:
many patients with acute and uncomplicated low back pain believe
that plain x-rays of the spinal column are important in a diagnosis,
they are not very helpful in most patients except for reducing
anxiety. Experts recommend waiting six to eight weeks. If pain
persists, then x-rays are usually warranted. In such cases,
they may reveal signs of injury, infection, tumors, stenosis,
or changes in the vertebrae that may be causing inflammation
or compression on the nerve. In nearly all cases of early back
pain, however, plain x-rays offer no benefit for diagnosis or
determining treatment unless a specific underlying cause is
- A discography
is an x-ray of the disc. It requires injections into discs suspected
of being the source of pain and discs nearby. It can be painful
and is generally only used for patients who are undergoing back
surgery to identify the location of the injured disc.
- A myelogram
is an x-ray of the spine that requires a spinal injection and
the need to lie still for several hours to avoid a very painful
headache. It has value only for select patients with pain on
moving and standing. It has largely been replaced by CT and
techniques should be used only when underlying infection, cancer,
or nerve involvement are suspected. Spinal abnormalities identified
by MRIs often do not predict long-term problems. Three-dimensional
CT scans and MRI refinements may soon make diagnosis more accurate.
have reported that MRIs miss between 6% and 23% of damaged discs
that were revealed during surgery.
- More importantly,
evidence now strongly suggests that the degree of disc abnormalities
revealed by MRIs have very little to do with the severity of
the pain or the need for surgery. Studies, in fact, indicate
that at least 40% of all adults have bulging or protruding
vertebrae discs, and most have no back pain. Discs abnormalities
in people who have back pain, then, may simply be a coincidence
rather than an indication for treatment. Many experts now believe
that relying on images of disc abnormalities to determine treatment
has resulted in many unnecessary surgeries.
Bone Scans and SPECT Imaging. In rare cases, bone scintigraphy
and single photon emission computed tomography (SPECT) may be used,
such as when bone abnormalities are suspected from conditions that
include spinal fracture, cancer that has spread to the bone, or
Blood and urine samples may be used to test for infections, arthritis,
or other conditions. Injecting a drug that blocks pain into the
nerves in the back helps locate the level in the spine where problems
occur. A procedure called a facet block is also useful in locating
areas of specific damage. Provocative discometry is a test that
uses an injection of saline solution into the suspected disc to
reproduce the pain, which is then followed by injection of an anesthetic
to dull the pain.
ARE TREATMENTS FOR UNCOMPLICATED ACUTE LOW BACK PAIN?
Approach for Uncomplicated Acute Low Back Pain or Sciatica
short-term acute low back pain, the best results derive from the
least aggressive treatments. The general approach is the following:
Back pain attributed
to medical conditions, such as arthritis, osteoporosis, or pregnancy,
either resolves when the condition does or is treated as part of
the overall therapeutic plan.
with no indication of any serious underlying cause should stay
as active as possible within the limits of the back pain. (Bed
rest is not recommended.) Studies suggest that a third
of patients with uncomplicated low back pain are significantly
improved after a week with no other treatment than normal activity
and two thirds have recovered by seven weeks.
therapy or spinal manipulations may be helpful if pain continues
for more than two weeks.
- The patients
should seek a specialist if pain continues for more than a month
(or less than this if there is indications for an underlying
disorder, nerve damage, or injury).
Treatment of Acute Low Back Pain of Unknown Cause
for Relieving Pain. At the onset of acute low back pain when
the cause is unknown the following tips may be helpful:
that Provide no Benefits
bed rest is no longer recommended, the patient should stop normal
physical activities for the first couple of days in order to
pain relievers often provide significant benefits. Muscle relaxants
may be helpful in some patients. Once started, medications should
be taken on a regular schedule in order to maintain consistent
- Many people
find that alternating ice packs and heating pads is helpful
in relieving the pain. Some people recommend changing from hot
to cold every three minutes and repeating this sequence three
times. (Some experts believe ice packs should be applied first.)
This regimen should be performed two or three times during the
day. (Heat or cold treatments do not have much effect on sciatica.)
back belts, braces, or corsets may help some people temporarily,
but they can reduce muscle tone over time and should be used
sleep plays a vital role in recovery. It is often difficult
to get a good night's sleep when suffering from back pain, particularly
because the pain can intensify at night. Take a warm bath before
bedtime, and practice relaxation techniques. It may be necessary
to take medication to help manage nighttime pain or treat sleeplessness.
To help promote sleep, avoid caffeine in the afternoon and evening.
Lying curled up in a fetal position with a pillow between the
knees or lying on the back with a pillow under the knees may
help. Pregnant women with back pain may find some relief by
placing a specially shaped pillow (eg, Ozzlo Pillow) under the
abdomen while sleeping.
not intensively studied, patients report that massage therapy
is helpful in some cases. It is is proving to be very helpful
for back pain in the acute and chronic phases.
manipulation may be helpful but some experts recommend delaying
this treatment until pain has persisted for three weeks, if
possible, since in many patients the back pain will have resolved
on its own by then.
Patients should be aware of and avoid certain approaches that are
not helpful and, in some cases may be harmful for acute low back
- Bed rest.
Bed rest for low back pain, including most cases of sciatica,
is no more effective and may even be worse than simply continuing
normal activities to the degree possible. Long-term bed rest
results in loss of muscle tone and bone strength, increases
susceptibility to blood clots, and causes depression and lethargy.
in the acute phases of low back pain. Intense exercise and physical
activity should be avoided during acute back pain, particularly
heavy lifting and trunk twisting. (Specific exercises can be
important during recovery, however, as well as for patients
with chronic low back pain.)
Acupuncture has not proven to have any value for acute low back
pain in most patients, but may provide some help for patients
with chronic low back pain.
therapy. Permanent bipolar magnets have gained some popularity
as a non-invasive method of relieving pain. To date no studies
support such claims and one 2000 study reported no effect in
alleviating low back pain. It should be noted that magnets can
deactivate heart devices and must be kept at least six inches
away from pacemakers or implantable cardioverter defibrillators.
Experts now recommend
that people with acute low back pain attempt to resume normal activities
as soon as possible. They should be conducted without strain or
stretching. Simply letting pain be the guide is the best approach
for achieving movement. In general, normal activity should be resumed
in a gradual fashion as soon as the patient feels ready, reserving
therapeutic exercises until after the acute pain has resolved.
Spinal Manipulation for Uncomplicated Acute Low Back Pain.
If pain persists beyond two to three weeks, at least one session
of spinal manipulation may be a useful treatment. There are a number
of variations, but one example of a spinal manipulation technique
is the following:
over whether on-going manipulations after a first visit work any
better for relieving pain than simply gradually resuming normal
activity. Some patients consider spinal manipulation to be highly
effective for chronic low back pain as well, although evidence in
this case is much weaker. Methodological problems have clouded the
results of many studies on manipulation techniques, and it is difficult
to draw valid conclusions from most of them.
- The patient
first lies on his or her side.
- The practitioner
grasps the exposed shoulder and either the hip or knee and then
presses the upper and lower portions of the body in opposite
directions, so that the torso rotates.
- The shifting
vertebrae make a cracking or popping sound, indicating that
they have exceeded the normal range of motion.
this results in a greater sense of ease and mobility. (The effect,
however, may be temporary).
Chiropractic or Osteopathy. Spinal manipulations are typically
performed by chiropractors but osteopathic doctors also perform
Effects. Both chiropractors and osteopaths offer verbal assurance
and a precise treatment regimen. The direct physical connection
through spinal manipulation reinforces the patient-practitioner
relationship. The emotional effects of such connections may be as
important for healing as the treatments themselves. Chiropractors
offer a further psychologic advantage, which is availability to
their patients. Many medical doctors believe that because low back
pain is self-limited and resolves, the patient can wait for an appointment.
A chiropractor, however, is more likely to accept to a patient promptly.
- One in
three people with low back pain seek treatment from a chiropractor.
Chiropractic was founded in the US in the late 1800s and has
been associated throughout its history with shamanism and folklore
as well as with potentially genuine health benefits. There has
not been a clear consensus even among its own practitioners
about its specific goals. Nevertheless, there is a strong movement
within the practice aimed at a scientific and realistic approach.
The specific goal of chiropractors is to perform spinal manipulations
to improve nerve transmission. Many studies have now confirmed
that patients feel more satisfied with their chiropractic care
than with treatment from general practitioners. (An analysis
of studies reported that chiropractic treatment was beneficial
but not significantly better than sham treatments. Interestingly,
standard medical treatments had worse results than both
chiropractic and sham treatments.)
was also founded in the 1800s and also involves physical manipulation
as its core approach to healing. Unlike chiropractic, however,
osteopathy uses manipulation of the bones, muscles, and tendons
to optimize blood circulation. In addition, the general direction
of osteopathy over the years has widened to employ a broader
range of treatments that now approach those of standard medicine.
One 1999 study reported that osteopathy was as effective as
medical treatment in relieving low back pain and patients required
far less medication and physical therapy. Osteopathic treatment
was also far less expensive.
Adverse Effects. Mild and temporary side effects from spinal
manipulation are common.
The potential for serious adverse effects from low back manipulations
is low. It should be strongly noted, however, that serious complications
(including stroke or spinal cord or neck injury) have been reported
with manipulations of the neck. Although little research
has been done on such complications, an English survey indicated
that they are more frequent than commonly thought.
Some chiropractors overuse x-rays, particularly those of the full
spine, which may have harmful consequences.
Patients should also be aware that some chiropractors use alternative
treatments that have not been proven or rigorously studied. All
patients should require objective evidence on the benefits of their
of nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants
such as cyclobenzaprine (Flexeril), diazepam (Valium), carisoprodol
(Soma), or methocarbamol (Robaxin) may be useful for some patients
with acute low back pain. Some experts argue, however, that it is
not clear which patients would benefit from them. In fact, in some
people the tensed back muscles may be protecting the damaged disc
or vertebrae, in which case medication to relax them could be harmful.
ARE THE TREATMENTS FOR CHRONIC BACK PAIN OF UNKNOWN CAUSES?
for Patients with Chronic Back Pain of Unknown Causes
A major review
of 12 studies indicated that only intensive treatment using a combination
of physical and psychologic rehabilitation programs reduced pain
and improved function in patients with chronic low back pain. It
should be noted that even with the best treatments, patients with
chronic back pain may not experience complete pain relief and may
need to develop methods for improving daily life in the face of
some persistent pain.
Massage therapy may be helpful for pain that has persisted for more
than three weeks. [See What Are Treatments for Uncomplicated Acute
Low Back Pain?]
and Physical Therapy. Specific and regular exercise under the
guidance of a trained professional is important for reducing
pain and improving function, although it is often very difficult
to sustain. [ See What Is the Role of Exercise and Movement
in Low Back Pain? .]
In some patients antidepressants may be helpful, particularly
those known as tricyclics.
- Pain Relievers.
Patients often take pain-relievers, particularly NSAIDs, although
they can have severe effects on the gastrointestinal tract over
time. Newer agents called COX-2 inhibitors may have fewer effects
on the GI tract, but their long-term safety is unknown. Some
physicians have recommended long-term opioids for patients with
severe chronic pain, but studies suggest they do not improve
activity levels and can have significant side effects.
Therapy. This form of psychologic therapy helps change behavior
and attitudes toward pain, and may be helpful for dealing with
Blocks. Procedures that block nerves in the pelvic area may
be used in severe cases.
Anti-inflammatory Drugs (NSAIDs)
The most commonly
prescribed medications for the treatment of chronic back pain are
nonsteroidal anti-inflammatory drugs (NSAIDs). These agents block
prostaglandins, the substances that dilate blood vessels and cause
inflammation and pain.
Common NSAIDs. There are dozens of NSAIDs. Some of the most
common are aspirin, ibuprofen, naproxen, and ketoprofen, but many
others are now available. [For other NSAIDs, see Box Ulcers
and Gastrointestinal Bleeding .] Regular use of even over-the-counter
NSAIDs may be hazardous for anyone and has been associated with
the following side effects:
and gastrointestinal bleeding. This is the major danger with
long-term use of NSAIDs. [ See Box Ulcers and Gastrointestinal
blood pressure. This is a particular problem for those on medications
to reduce hypertension. Piroxicam (Feldene), naproxen (Aleve),
and indomethacin (Indocin) appear to pose the greatest risks
for high blood pressure. (Sulindac has the smallest effect.)
People with hypertension, severe vascular disease, kidney or
liver problems, and those taking diuretics must be closely monitored
if they need to take NSAIDs.
- They may
delay the emptying of the stomach, which could interfere with
the actions of other drugs. The elderly are at special risk.
ringing in the ear.
- Skin rash.
has also been noted.
or bizarre sensation (in some higher-potency NSAIDs, such as
abnormalities have been reported in people taking NSAIDs, which
resolves when the drugs are withdrawn. Any sudden weight gain
or swelling should be reported to a physician.
taking oral hypoglycemics may need to adjust the dosage if they
also need to take NSAIDs because of possible harmful interactions
between the drugs.
Ulcers and Gastrointestinal Bleeding
are a major cause of ulcers and gastrointestinal (GI) bleeding.
Gastrointestinal complications from the use of NSAIDs account
for almost 100,000 hospitalizations and at least 16,000 deaths
a year in the United States. Bleeding and ulcers can occur
at any time, with or without symptoms. One study indicated
that taking NSAIDs for only six months posed a risk for symptomatic
ulcers that was greater than 1%. The risk for bleeding is
continuous as long as a patient is on these drugs and may
even persist as long as a year after the drug is discontinued.
Alcohol abuse may increase the risk for GI bleeding when taking
NSAIDs. Because NSAIDs reduce the clotting of the blood, anyone
undergoing surgery should stop taking the medication a week
before the operation.
Ulcer Risk for Specific NSAIDs. One study ranked the
sixteen most commonly used NSAIDs according to risk for ulcers
risk: flurbiprofen (Ansaid), piroxicam (Feldene), fenoprofen,
indomethacin (Indocin), meclofenamate (Meclomen), and oxaprozin.
Lowest Risk: nabumetone (Relafen), etodolac (Lodine),
salsalate, and sulindac (Clinoril).
Medium risk: diclofenac (Voltaren), ibuprofen (Motrin,
Advil, Nuprin, Rufen), aspirin, naproxen (Aleve, Naprosyn,
Naprelan, Anaprox), and tolmetin (Tolectin). (Drugs within
this group vary in risk. Studies show, for example, that
short-term use of naproxen is twice as likely as ibuprofen
to be associated with hospitalization from GI bleeding.
Although ketoprofen (Actron, Orudis KT) was considered
a medium-risk drug, another study reported that even one
week of taking the drug at low doses causes significant
Drugs for Prevention of NSAID-Induced Ulcers. For people
who need to take NSAIDs regularly, some agents are available
that may protect against bleeding and ulcers.
Proton-pump inhibitors include omeprazole (Prilosec),
lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprozole.
Proton pump inhibitors are possibly the most protective
agents and can actually heal existing ulcers. Their use
has been demonstrated to reduce NSAID-ulcer rates by as
much as 80% compared with no treatment.
Misoprostol is a prostaglandin, the protective substance
blocked by NSAID use. It protects against the major intestinal
toxicity of NSAIDs. It is used to prevent NSAID-induced
ulcers, both duodenal and gastric, but is not useful in
healing existing ulcers.
Blockers. Some H2 blockers may help prevent NSAID-induced
ulcers. These drugs are available over the counter and
include famotidine (Pepcid AC), ranitidine (Zantac), cimetidine
(Tagamet), and nizatidine (Axid). In one 2000 study, ranitidine
and famotidine were associated with a lower risk for bleeding
in patients taking NSAIDs, but another study found no
protection from cimetidine.
COX-2 Inhibitors. Celecoxib (Celebrex), rofecoxib (Vioxx),
and meloxicam (Mobic) are known as COX-2 (cyclooxygenase-2) inhibitors,
the so-called super-aspirins.
Benefits. These agents may prove to be as effective and less
harmful to the GI tract than NSAIDs. Importantly, studies are reporting
a lower incidence of ulcers and other toxic side effects in patients
taking the COX-2 inhibitors than in those taking NSAIDs. The drugs
were all equally effective in relieving pain. (One study compared
celecoxib with the NSAIDs ibuprofen or diclofenac and the other
compared rofecoxib with the NSAID naproxen.) One 1999 study even
found the rate of GI problems with celecoxib was equal to that in
people who do not take NSAIDs at all. COX-2 inhibitors are currently
more expensive than traditional NSAIDs, however, and some insurers
do not pay for them.
Theoretically, they may even have properties that produce less adverse
effects on cartilage than NSAIDs may have.
Some early evidence also suggests they may be protective against
colon cancer and possibly even Alzheimer's disease.
Possible Negative Effects. In spite of their promise, some
researchers theorize that inhibiting COX-2 may have some negative
side effects over the long term:
is needed to confirm or refute any possible hazard.
COX-2 inhibitors are very likely to have a lower risk for ulcers
and GI bleeding than standard NSAIDs, studies have been mixed
on whether patients taking COX-2 inhibitors have the same gastrointestinal
symptoms (eg, diarrhea, abdominal discomfort) as standard
NSAIDs. Vioxx may pose a higher risk for symptoms than Celebrex.
(Other side effects found with short-term use include headache,
- One 2000
study observed that the COX-2 inhibitors had some adverse effects
on kidney function, particularly in elderly people, that were
similar to the effects of standard NSAIDs. This effect can also
trigger fluid build up and high blood pressure. (Celebrex may
have fewer of these effects than Vioxx.)
taking anticoagulant drugs may experience a higher risk for
bleeding with the use of these agents.
are reporting a higher incidence of heart attacks in patients
taking Vioxx and possibly Celebrex than in those taking the
standard NSAID naproxen. Some evidence suggests that both COX-2
inhibitors may increase the risk for blood clots. Experts also
suggest that heart patients with chronic pain may be substituting
COX-2 inhibitors for heart-protective NSAIDs (such as aspirin,
ibuprofen, or possibly naproxen). Patients with heart disease
who are taking low-dose aspirin should continue it even while
they are taking COX-2 inhibitors.
- A few
cases of psychiatric side effects (hallucinations), fluid build
up, high blood pressure, and excess potassium in the blood has
been observed with higher doses of celecoxib or rofecoxib.
- They may
have negative effects on pregnancy and fertility.
- No one
who has allergic reactions, hives, or asthma from sulfa drugs,
aspirin, or other NSAIDs, should take a COX-2 inhibitor.
- The use
of COX-2 inhibitors can interfere with many other drugs taken
concurrently, including many taken for heart disease and high
blood pressure. Patients should discuss all other medications
with their physician.
Some experts suggest that treating people with low back pain and
depression for the psychological condition may be more beneficial
and cost-effective than back treatments. Certain antidepressants,
called tricyclics, can even be effective pain killers in non-depressed
people with chronic back pain. They include amitriptyline (Elavil,
Endep), desipramine (Norpramin), doxepin (Sinequan), imipramine
(Tofranil), amoxapine (Asendin), nortriptyline (Pamelor, Aventyl),
and maprotiline (Ludiomill). It should be noted that tricyclics
can have severe side effects. Nonetheless, experts believe there
is a useful role for these drugs that warrants further investigation.
Unless the pain is very severe, experts advise against routinely
prescribing pain killers containing opioids (eg, morphine, codeine,
meperidine [Demerol], oxycodone [Oxycontin], or tramadol). A skin
patch containing an opioid called transdermal fentanyl (Duragesic)
may relieve chronic back pain more effectively than oral opioids.
Side effects for all opioids include drowsiness, impaired judgment,
nausea, and constipation. Addiction is a risk, although less than
is commonly believed when these medications are used for pain relief.
Reduction and Behavioral Techniques
a 2001 review of studies, only intensive programs that include psychologic
as well physical rehabilitation therapies were successful in reducing
and improving function in patients with chronic low back pain.
Stress Reduction. Stress reducing techniques, including
relaxation methods and meditation, may be helpful. One study, for
example, reported that meditation was beneficial in reducing pain
and improving mood among chronic pain sufferers who had not responded
to traditional care.
Cognitive-Behavioral Therapy. Studies report that a course
of cognitive-behavioral therapy helps reduce chronic back pain and
enhances the patient's ability to deal with it. The primary goal
of cognitive therapy in such cases is to change the distorted perceptions
that patients have of themselves and their approach to pain. Using
specific tasks and self-observation, patients gradually shift their
fixed ideas that they are helpless against the pain that dominates
their lives to the perception that pain is only one negative and,
to a degree, a manageable experience among many positive ones. In
one study, therapists also taught relaxation techniques and methods
to improve posture. The sessions were two and a half hours each
week for 12 weeks. More research is needed.
To date, no strong
studies have been conducted to verify the effects of massage therapy.
Small recent ones, however, have indicated that it is as effective
as spinal manipulation and more effective than acupuncture or self-care.
For example a 2001 study comparing massage therapy with Traditional
Chinese Medical acupuncture and self-care found massage to be more
effective than either at ten weeks and it produced significantly
better results than the acupuncture after a year. (None of these
approaches, however, offered complete relief.)
decompression (VAX-D) is proving to reduce pain and improve function
in patients wwith chronic low back pain. The therapy employs a special
table that controls adjustments along the lines of the spinal column.
Some evidence supports its benefits.
Herbal Remedies. There have been claims for a number of
herbal and so-called natural remedies for relief of back pain. One
study of extracts of harpagophytum (a South African herb commonly
called Devil's Claw or Grapple Plant) showed some promise. Herbal
remedies for back pain may include relaxants such as black haw (viburnum
prunifolium) or valerian (valeriana officinalis), anti-inflammatories
such as turmeric (curcuma longa) or arnica montana (for external
use only), circulatory stimulants such as gingko biloba or rosemary,
and pain relievers such as white willow bark (salix alba). It should
be strongly noted that if any substance has beneficial effects against
serious illness it also, like any drug, most likely has side effects
and may even be harmful for some people. In addition, herbal and
so-called natural remedies are not regulated, few studies have been
conducted on any of these products, and the quality or safety cannot
be guaranteed. [See Warnings on Alternative and So-Called Natural
Warnings on Alternative and So-Called Natural Remedies
be strongly noted that alternative or natural remedies are
not regulated and their quality is not publicly controlled.
In addition, any substance that can affect the body's chemistry
can, like any drug, produce side effects that may be harmful.
Even if studies report positive benefits from herbal remedies,
the compounds used in such studies are, in most cases, not
what are being marketed to the public.
There have been a number of reported cases of serious and
even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard
prescription medication. Most problems reported occur in herbal
remedies imported from Asia, with one study reporting a significant
percentage of such remedies containing toxic metals.
The following website is building a database of natural remedy
brands that it tests and rates. Not all are available yet.
The Food and Drug Administration has a program called MEDWATCH
for people to report adverse reactions to untested substances,
such as herbal remedies and vitamins (call 800-332-1088).
Transcutaneous Electric Nerve Stimulation. Transcutaneous
electric nerve stimulation (TENS) uses low-level electrical pulses
to suppress back pain. The standard approach is to give 80 to 100
pulses per second for 45 minutes three times a day. The patients
are barely aware of the sensation. A variant (sometimes called percutaneous
electrical nerve stimulation or PENS) applies these pulses through
a small needle to acupuncture points. A 2000 analysis of studies
report that either TENS or PENS appears to offer some relief for
chronic low back pain, at least temporarily. PENS may be more effective.
It may help men more than women. In any case, neither approach appears
to be helpful for relief of acute low back pain in most patients.
Acupuncture. Acupuncture is now a common alternative treatment
for certain kinds of pain. It involves inserting small pins or exerting
pressure on certain "energy" points in the body. When the needles
have been placed successfully, the patient is supposed to experience
a sensation known as Teh Chi, which brings a feeling of fullness,
numbness, tingling, and warmth with some soreness around the acupuncture
point. Unfortunately, the strongest evidence to date suggests that,
in general, acupuncture does not have a major effect on low back
pain. Still it may be helpful for certain patients with back pain,
such as pregnant women, who must avoid medications. Anyone who has
acupuncture should be sure it is performed in a reputable location
with experienced practitioners who use sterilized equipment.
IS THE ROLE OF EXERCISE AND MOVEMENT IN LOW BACK PAIN?
Activity Levels after Acute Back Pain
may be as unhelpful as prolonged bed rest during acute back pain.
(In one study, recovery from acute back pain was slower for patients
who immediately embarked on flexibility exercises than for those
who gradually resumed normal activity.) Walking, stationary biking,
swimming, and even light jogging, however, may begin within two
weeks of symptoms. An incremental aerobic exercise program is less
stressful than stretching or performing exercises that strengthen
the trunk muscles. Patients should never force themselves to exercise
if, by doing so, pain increases.
Exercises to Avoid during Recovery. It should be strongly
noted that incorrect movements or long-term high-impact exercise
is a cause of back pain. People vulnerable to back pain should avoid
activities that put undue stress on the lower back or require sudden
twisting movements, such as football, golf, ballet, and weight lifting.
Jogging is usually not recommended, at least not until the pain
is gone and muscles are stronger. Exercises that put the lower back
under pressure should be avoided until the back muscles are well
toned. Such exercises include leg lifts done in a prone (face-down)
position, straight leg sit-ups, and leg curls using exercise equipment.
Role of Physical Therapy
with a trained professional may be useful if pain has not improved
within the first three weeks. It is, in fact, important for any
person who has chronic low back pain to have an exercise program
guided by professionals who understand the limitations and special
needs of back pain and who can address individual health conditions.
One study indicated that patients who planned their own exercise
did worse than those in physical therapy or physician-directed programs.
Physical therapy typically includes the following:
- The first
stage involves patient education and training the patient in
correct movement. Sometimes heat or electro-therapies are employed,
although their benefits are unproven.
- If back
pain has continued beyond five weeks, physical therapy is used
for rehabilitation. It employs exercises to help the patients
keep the spine in neutral positions during all daily activities.
for Chronic Back Pain
a very beneficial role in chronic back pain. In one study, for example,
patients with back pain lasting for an average of 18 months were
assigned eight one-hour exercise sessions over four weeks. They
showed greater improvement in nearly every area, including reduced
pain and increased capacity, compared to patients who did not exercise.
The positive benefits of exercise not only affect strength and flexibility
but they also alter and improve the patients' attitudes toward their
disability and pain.
Repetition is the key to increasing flexibility, building endurance,
and strengthening the specific muscles needed to support and neutralize
the spine. Some exercise programs used for prevention or for chronic
low back pain include the following:
Impact Aerobic Exercises. Low-impact aerobic exercises,
such as swimming, bicycling, and walking, can strengthen muscles
in the abdomen and back without over-straining the back. Programs
that use strengthening exercises while swimming may be a particularly
beneficial approach for many patients with back pain.
Extension Strength Training. Exercises called lumbar extension
strength training are proving to be effective. Generally, these
exercises attempt to strengthen the abdomen, improve lower back
mobility, strength, and endurance, and enhance flexibility in
the hip and hamstring muscles and tendons at the back of the
thigh. [For examples of some good exercises for the back, see
Tai Chi, and Chi Kung. These exercises combine low-impact
physical movements and meditation. They are based on principles
of disciplining the mind to achieve a physical and mental balance
and can be very helpful in preventing recurrences of lower back
Exercises. Whether flexibility exercises alone offer any
significant benefit is uncertain. One study suggested that any
benefits derived from flexibility exercises are lost unless
the exercise regimens are sustained.
Deep Muscles. Of interest are studies that are finding
a link between low back pain and impaired motor control of deep
muscles of the back and trunk. According to these studies, contraction
exercises specifically designed to retrain these muscles may
be effective for patients with both acute and chronic pain.
Exercises for Low Back Strength
Perform the following exercises at least three times a week:
Partial Sit-ups. Partial sit-ups or crunches strengthen
the abdominal muscles.
Keep the knees bent and the lower back flat on the floor while
raising the shoulders up three to six inches.
Exhale on the way up and inhale on the way down.
Perform this exercise slowly eight to ten times with the arms
across the chest.
Pelvic Tilt. The pelvic tilt alleviates tight or fatigued
lower back muscles.
increase this exercise until it is held for five seconds.
Then, extend the legs a little more so that the feet are further
away from the body and try it again.
Lie on the back with the knees bent and feet flat on the
Tighten the buttocks and abdomen so that they tip up slightly.
Press the lower back to the floor, hold for one second
and then relax.
Be sure to breathe evenly.
Stretching Lower-Back Muscles. The following are three
exercises for stretching the lower back:
one with low back pain should perform exercises that require
bending over right after getting up in the morning. At that
time, the discs are more fluid-filled and more vulnerable
to pressure from this movement.
Lie on the back with knees bent and legs together. Keeping
arms at the sides, slowly roll the knees over to one side
until totally relaxed. Hold this position for about 20
seconds (while breathing evenly) and then repeat on the
Lying on the back, hold one knee and pull it gently toward
the chest. Hold for 20 seconds. Repeat with other knee.
While supported on hands and knees, lift and straighten
right hand and left leg at the same time. Hold for three
seconds while tightening the abdominal muscles. The back
should be straight. Alternate with the other arm and leg
and repeat on each side eight to 20 times.
for Daily Movement and Inactivity
The way a person
moves, stands, or sleeps during the day plays a major role in back
good posture is very important. This means keeping the ears,
shoulders, and hips in a straight line with the head up and
stomach pulled in. It is best not to stand for long periods
of time. If it is necessary, walk as much as possible and wear
shoes without heels, preferably with cushioned soles. Using
a low stool, alternate resting each foot on it.
puts the most pressure on the back. Chairs should either have
straight backs or low-back support. If possible, chairs should
swivel to avoid twisting at the waist, have arm rests, and adjustable
backs. While sitting, the knees should be a little higher than
the hip, so a low stool or hassock is useful to put the feet
on. A small pillow or rolled towel behind the lower back helps
relieve pressure while either sitting or driving.
and particularly driving for long periods in a vehicle increases
stress. Move the seat as far forward as possible to avoid bending
forward. The back of the seat should be reclined not more than
30° and, if possible, the seat bottom should be tilted
slightly up in front. For long rides, one should stop and walk
around about every hour and avoid lifting or carrying objects
immediately after the ride.
- Be sure
to have a firm mattress. If the mattress is too soft, a 1/4-inch
plywood board can be put between the mattress and box spring.
On the other hand, some people have experienced morning backache
from a mattress that is too hard. The back is the best guide.
for Lifting and Bending
Anyone who engages
in heavy lifting should take precautions when lifting and bending:
- If an
object is too heavy or awkward, get help.
your feet apart to give a wide base of support.
as close as possible to the object being lifted.
- Bend at
the knees; tighten stomach muscles and tuck buttocks in so that
the pelvis is rolled under and the small of the back is flexed
slightly. Do not arch the back. (Even when not lifting an object,
always try to use this posture when stooping down).
- Hold objects
close to the body to reduce the load on the back.
- Lift using
the leg muscles, not those in the back.
up without bending forward from the waist.
twist from the waist while bending or lifting any heavy object.
If you need to move an object to one side, point your toes in
that direction and pivot toward it.
- If an
object can be moved without lifting, pull it, don't push.
ARE TREATMENTS FOR SEVERE LOW BACK PAIN (HERNIATED DISC OR SPINAL
Approach to Severe Low Back Pain
It is important that any serious medical causes as well as
cauda equina syndrome and progressive nerve damage be ruled out
first. In general, early treatments for severe low back pain or
for episodes of chronic low back pain are similar to those of acute
uncomplicated low back pain, including avoiding bed rest. If common
pain relievers, such as NSAIDs are not effective, narcotic agents
may be needed for a limited period. Corticosteroid injections may
be helpful for some patients.
Approach for Patients with Herniated Discs:
Patients with Spinal Stenosis
Procedures. In patients with herniated discs, non surgical methods
should be used for at least a month before considering surgery.
Non surgical procedures include spinal manipulation, massage
therapy, and physical therapy. (Patients should wait at least
two to three weeks before using spinal manipulation, since early
effectiveness and safety are not yet clear.)
According to a 2001 review of studies, about 10% of patients
experience pain after six weeks that is severe enough to warrant
consideration of discectomy, the standard procedure for herniated
disks. For many of these patients, surgery may bring significant
relief. In one 2001 study, for example, 70% of patients with
moderate to severe sciatica who had had surgery reported improvement.
And the improvement is superior to that from nonsurgical treatments
for about four years in most patients. After that, and by ten
years, however, it is not clear if surgery maintains its advantage
over nonsurgical approaches.
Falls. Falling is a risk for patients with spinal stenosis.
They should avoid alcohol and sedatives. Leg strengthening exercises
(walking, cycling) may be helpful, with brief resting if pain
Treatments. The use of common pain relievers, such as NSAIDs,
physical therapy, and steroid or other spinal injections may
be helpful for some patients.
If pain is persistent, patients may require surgery, most often
a procedure called decompressive laminectomy. Some patients
may require spinal fusion as well. Studies suggest that surgery
reduces back pain in many patients, at least for a few years.
By four years after surgery, however, 30% of patients have severe
pain again and 10% have had another operation. It should be
noted that surgery does not always improve outcome and in some
cases can even make it worse. Surgery can be an extremely effective
approach, however, for certain patients with severe back pain
that does not respond to conservative measures.
Injections of different substances are sometimes used to treat low
back pain caused by nerve impingement. The injection is usually
an epidural, which is directed into the spaces between the outer
membrane of the spine and the vertebrae. None of these substances
cure the problem.
A one-time injection of a corticosteroid (commonly called a
steroid) is directed as close to the injured location as possible.
Corticosteroids reduce inflammation and this approach may short-cut
sciatic pain until the body heals itself. This is a temporary,
not permanent, solution. Studies that measure the benefits of
steroids on sciatica or low back pain, however, are conflicting.
In fact there is some evidence that patients can experience
a rebound effect within a few months and the pain returns.
saline (salt water solution). Epidural injections of saline
are being investigated for breaking up scar tissue. One 2001
study compared targeted injections of saline and steroids directed
at the nerve root. Although steroid injections had more immediate
benefits, both offered improvement, and by three months, patients
who had saline injections experienced less pain than the steroid
anesthetics. Injections of anesthetics such as xylocaine
or bupivacaine may also help some patients.
Injections of botulinum toxin (Botox) in the lower back
are under investigation. Very small amounts of the bacterial
toxin temporarily paralyze muscle tissue. Studies in 2000 and
2001 reported that Botox relieved pain by at least half in between
60% and 78% of patients compared to between 12% and 28% who
reported the same benefit from placebo. The participants experienced
no adverse effects. In the 2001 study, however, the benefits
of Botox injections did subside by six months.
The rate of all
types of back surgery is more than 40% higher in the US than in
any other country. Surgical treatments for low back pain rose from
190,000 in 1983 to 335,000 in 1994.
The most common reasons for surgery for low back pain are sciatica
and spinal stenosis. Evidence of a herniated disc and nerve compression,
however, is not an automatic indication for surgery. It is advised
only for selected patients. (For example, the best spinal stenosis
candidates are those with a condition known as block spinal stenosis.)
Some experts believe that less than 1% of back pain patients need
aggressive medical or surgical treatments.
The primary indication for surgery is the following:
Pain that has existed for over four months, has not responded to
conservative treatments, and is so debilitating that it interferes
with normal functioning.
Other, specific indications for surgery include the following:
A patient should
be sure that the surgeon has had significant experience with any
procedure to be performed. Research indicates that surgery may have
better short-term effects than medical treatment (in terms of immediate
employability and functioning), but that in the long-term they are
weakening in the legs.
of some physical abnormality of the spine, such as a bone spur.
of cauda equina syndrome, in which an emergency operation may
need to be performed to avoid permanent damage.
Standard Surgery. Discectomy is the surgical removal of
the diseased disc, thereby relieving pressure on the spine. In spite
of the fact that discectomy has been performed for 40 years, few
studies have been conducted to determine its real effectiveness.
A 2000 analysis of previous studies reported that it appeared to
offer faster relief than medical treatment, but long-term superiority
is uncertain. Although less invasive techniques are being developed
and described below, at this time they are no more effective than
the standard approach. One 2001 study indicated that patients who
undergo surgery for moderate to severe sciatica have somewhat better
improvement in symptoms after five years than those who receive
nonsurgical treatments. The benefits of surgery decrease over time,
Endoscopic Discectomy. Less invasive endoscopic variations
are proving to be effective for some patients. Endoscopy employs
a catheter (a thin tube) that contains tiny cameras and surgical
instruments that are inserted through small incisions. Various endoscopic
approaches are proving to be useful.
argue that endoscopic procedures are rarely useful and patients
often need repeat operations. Nevertheless, they pose a lower risk
for complications than major surgery and some experts urge they
be used for selected patients.
discectomy (PAD) uses a tube with a device at the tip that cuts
away some of the nucleus pulposus and a vacuum that then sucks
this gelatinous matter out. This procedure is also being investigated
for disks that have tears in the annular rings.
laser foraminoplasty (ELF) is a minimally-invasive procedure
that is proving to be effective and to have fewer complications
than other spinal surgeries. It employs lasers to locate the
likely source of pain and remove diseased tissue with minimal
Complications. Scar tissue is a significant problem, since
it can cause persistent low back pain afterward. Anti-scarring agents
or certain devices may help reduce surgical scars and thereby postoperative
Laminectomy or Laminotomy
Operations that shave off part of a vertebra (laminotomy) or remove
all of it (laminectomy) may be used in certain cases of spinal stenosis
or spondylolisthesis to decompress the nerve. It may also be used
to remove benign tumors on the spine. Although either procedure
often brings immediate relief from pain, a 1999 statistical study
suggested that it is inappropriately performed in 60% or more of
sciatica cases. There are small risks to the operation and it is
not always successful. Some recurrence of back pain and sciatica
occurs in half to two-thirds of postoperative patients. One study
reported that the operation in children and young adults can increase
the risk for spinal deformity.
In cases where abnormal positioning or vertebrae movement puts pressure
on the nerves, such as spinal stenosis or spondylolisthesis, surgeons
may fuse vertebrae together. (It is not clear, however, whether
fusion is any more effective for stenosis or spondylolisthesis than
procedures for reducing disc pressure.) Fusion employs a bone graft
or some other device to join the vertebrae together. One medical
device uses a tiny hollow metal cage, which is implanted into the
disc space. Bone is removed from the patient and packed inside the
cage; over time the bone grows through the holes and around the
device, fusing the vertebrae. In one study, the device was successful
in 72% of patients, reducing pain without any loss of muscle strength
Postoperative Period: Complications and Outlook
Many patients still have back pain after discectomy that delays
discharge from the hospital. Narcotics are usually needed; adding
an injected NSAID may speed resolution of pain. It should be noted
that one study reported that an injected NSAID after fusion procedures
may reduce the chances for successful bone healing and union. Other
complications of spinal surgery can include nerve and muscle damage,
infection, scarring, and the need for reoperation. Patients now
often remain in bed only three or four days after disc surgery;
studies indicate that such patients have the same or even fewer
complications than those who stay in bed for weeks. It may take
four to six weeks for full recovery. Gentle exercise may be recommended.
Intradiscal Electrothermal Treatment. A promising procedure
known as intradiscal electrothermal treatment (IDET) employs a probe
that uses electricity to heat the injured disc tissue, specifically
the annular ring nerve fibers. Heat is applied for about 17 minutes.
After healing, the disc is toughened and desensitized. It requires
a substantial post-operative recovery period, but may prove to be
a less invasive alternative to surgery. Early reports are promising,
but use is not yet widespread and long-term risks and benefits are
Nerve Blocks. A number of surgical techniques are available
for relieving pain by impairing nerves that are causing pain due
to impingement. In one 2000 study that used electrical stimulation
to block the nerves, 60% of the patients reported at least 90% relief
of pain after a year, and 87% reported at least 60% relief.
ELSE CAN INFORMATION ABOUT LOW BACK PAIN BE OBTAINED?
American Physical Therapy Association, 1111 N. Fairfax St., Alexandra,
VA 22314-1148. Call (703-684-2782) or (800-999-2782) on the Internet
American Academy of Orthopaedic Surgeons, 6300 N. River Road, Rosemont,
IL 60018-4262. Call (847-823-7186) or (800-346-AAOS) on the Internet
President's Council on Physical Fitness and Sports, Department W,
200 Independence Ave., S.W., Room 738-H, Washington, DC 20201-0004.
Call (202-690-9000) for general information on exercise and fitness.
The council publishes Physical Activity and Fitness Research
National Arthritis and Musculoskeletal and Skin Diseases, Information
Clearinghouse, National Institutes of Health, 1 AMS Circle, Bethesda,
Maryland 20892-3675. Call (301-495-4484 ) or on the Internet (https://www.nih.gov/niams/)
National Institute for Occupational Safety and Health (NIOSH), 4676
Columbia Parkway, Cincinnati OH 45226. Call (800-356-4674) or on
the Internet (https://www.cdc.gov/niosh/homepage.html)
American Chronic Pain Association, P.O. Box 850, Rocklin, CA 95677.
Call (916) 632-0922 or on the Internet (https://www.theacpa.org/)
National Chronic Pain Outreach Association. Call (540-862-9437)
American Pain Society, 4700 W. Lake Avenue, Glenview, IL 60025.
Call (847-375-4715) or on the Internet (https://www.ampainsoc.org)
International Association for the Study of Pain, 909 NE 43rd St.,
Suite 306, Seattle, WA 98105-6020. Call (206-547-6409) or on the
The National Association for Chiropractic Medicine, 15427 Baybrook
Drive, Houston, TX 77062. Call (281-280-8262) or on the Internet
This association believes that chiropracty should be limited to
treating joint conditions using scientific prinicples. (The other
two chiropractice organizations are more controversial and tend
toward alternative treatments. American Chiropractors' Association
stresses vitamins and natural diets as well as joint conditioning.
The International Chiropractors' Association still advocates 19th
century principles of relating pinched nerves to overall health.)
BackCycler. Call (800-959-3746) ) or on the Internet (https://www.backcycler.com/)
BackCycler is a device designed by orthopedists at the Spine Institute
of New England to alleviate the discomfort of sitting in a car or
North American Spine Society 22 Calendar Ct. 2nd Floor LaGrange,
IL 60525 Phone: (708) 588-8080 Fax: (708) 588-1080 https://www.spine.org/
American Physical Therapy Association 1111 North Fairfax St. Alexandria,
VA 22314-1488 Phone: (703) 684-2782 Toll-free: (800) 999-2782 Fax:
(703) 684-7343 https://www.apta.org/
Arthritis Foundation 1330 West Peachtree St. Atlanta, GA 30309 Phone:
(404) 872-7100 Toll-free: (800) 283-7800 https://www.arthritis.org/
The International Intradiscal Therapy Society (IITS) (https://www.iits.org)
International Spinal Injection Society (https://www.spinalinjection.com/)
This site provides results of independent tests of the quality and
potency of herbal and nutritional products. (https://www.consumerlab.com)
Resources for injured workers: https://www.workerscompensationinsurance.com.
New York Committee for Occupational Safety and Health. (https://www.nycosh.org).
For additional, updated information on OSHA's
ergonomics rule, visit "The Clipping File," part of the Health &
News section of the NYCOSH website.
Illustrations of Back Surgery
Site has good description of back procedures (https://www.spine-surgery.com)
Another site with good descriptions of back operations (https://www.yoursurgery.com)