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Chronic Back Pain

At some point during our adult lives, most people experience bouts of back pain. Chronic back pain is pain that persists after an injury or surgery where the source is hard to determine. Acute pain can develop into Chronic Pain for a number of reasons. Once these reasons have been determined through a medical evaluation, treatment can focus on reducing back pain and improving mood and function.

Prevalence

Back pain and related symptoms rank among the second most frequent medical complaints. Disability from low back pain is second only to the common cold as a cause of lost work time and is the most common cause of disability in people under 45 years of age.

In the United States, the lifetime prevalence of back pain is approximately 80%, with a one-year prevalence rate of 15% to 20%„the highest prevalence is in the 45 to 64 age group.

Natural-history

In reality, the natural history of acute low back pain is very favorable and the same is true for sciatica (an inflammation of the sciatic nerve, characterized by pain and tenderness through the thigh and leg):

  • 60% recover in 1 to 3 weeks;
  • 90% recover in 6 to 8 weeks; and
  • 95% recover in 12 weeks.
  • Serious causes of low back pain (e.g. cancer) are uncommon (less than 1%).
Mechanisms

The onset of acute low back pain most often is the result of mechanical damage due to excessive and prolonged poor posture and mechanics, a sedentary lifestyle and inadequate conditioning. Seemingly trivial stress such as bending over, sneezing or coughing can produce a herniated disc when superimposed on chronic wear and tear. People in a sedentary occupation have a high risk of herniating a disc.

During the flexion that occurs with sitting, intradiscal pressure is greatest and the disc exerts pressure on the thinnest, least supported area of the supporting ligament known as the annulus fibrosus. As a result, the disc can herniate.

Mechanical low back pain may be defined as pain secondary to overuse of a normal anatomic structure (muscle strain) or pain secondary to injury or deformity of an anatomic structure (herniated nucleus pulporus). Mechanical low back pain is usually aggravated by static loading of the spine (prolonged sitting or standing), long levered activities (e.g. vacuuming) or levered postures (bending forward). It is eased when the spine is balanced by multidirectional forces (e.g., walking) or when the spine is unloaded (e.g., reclining).

Mechanical conditions of the spine including back strain, disc herniation, disc disease, osteoarthritis and spinal stenosis account for up to 98% of cases of back pain.

Management

The history and physical examination is the first step in the evaluation and management of low back pain. Based on this information and specific guidelines, x-rays may be ordered; however, not every patient with low back pain requires x-rays.

Since the natural history of low back pain is favorable, most patients can start initial and usually successful therapy without the benefit of x-rays, a CT scan or MRI scan. Though radiographic evaluation may identify anatomic alterations in the lumbar spine, studies have shown that these may correlate poorly with the presence or severity of low back pain. The physician must take all the clinical data together and formulate a diagnosis and treatment plan based upon all the collected information. The physician does not want to intervene with inappropriate surgery nor overlook the possibility of a serious complication associated with a mechanical disorder (cauda equina syndrome) or a secondary cause of back pain (malignancy); the latter can be identified in the history and physical by certain "red flags."

The majority of patients will improve with controlled physical activity, physical therapy, nonaddictive non-steroidal anti-inflammatory drugs, and, in appropriate patients, muscle relaxants. Surgical invention is reserved for the patient who has not shown improvement on conservative therapy and has undeniable symptoms and signs (sciatica) associated with a mechanical disorder (herniated disc) that can be corrected by surgical intervention.

Chronic low back pain is a complex disorder that must be managed with a multi-disciplinary approach that addresses the physical, psychologic and socioeconomic aspects of the illness. Fortunately, chronic low back pain affects only a small percentage of patients.

Prevention

Obesity and smoking correlate unfavorably with low back pain and may adversely affect the progression of the disorder. Overall physical fitness will correlate favorably with recovery from low back pain and return to work. Training, education and ergonomic intervention may reduce the incidence of back disorders.

Sports

The competitive athlete and most individuals who exercise regularly maintaining a level of fitness, are less prone to lumbar spine injury and problems due to the strength and flexibility of supporting structures. These structures include strong abdominal and lumbar paraspinal muscles for support, and flexible gluteal and hamstring muscles.

Problems involving the lumbar spine are rare in athletes and account for less than 10% of sports-related injuries. Sports such as gymnastics, football and racquet sports have a higher incidence of associated lumbar spine problems related to repetitive twisting and bending motions. Most injuries are minor, self-limited and respond quickly to conservative treatment. The incidence of lumbar spine problems with the casual or weekend athlete may be higher and related to the individual's level of fitness. Prevention through proper conditioning and technique is important.

What can I do if I have acute low back pain?

The key to recovering from acute (abrupt, intense pain that subsides after a relatively short period) low back pain is maintaining the hollow or lordosis (the normal curvature of the spine). Supporting the hollow of your back will help shorten your recovery time.

For 10 to 20 days after you experience acute low back pain, follow these guidelines:

Sitting
  • Sit as little as possible, and only for short periods of time (10 to 15 minutes).
  • Sit with a back support (such as a rolled-up towel) placed at the hollow of your back.
  • Keep your hips and knees at a right angle (use a foot rest or stool if necessary). Your legs should not be crossed and your feet should be flat on the floor.

Here's how to find a good sitting position when you're not using a back support or lumbar roll

  • Sit at the end of your chair and slouch completely.
  • Draw yourself up and accentuate the curve of your back as far as possible.
  • Hold for a few seconds.
  • Release the position slightly (about 10 degrees). This is a good sitting posture.
  • Sit in a high-back chair with arm rests. Sitting in a soft couch or chair will tend to make you round your back and won't support the hollow of your back.
  • At work, adjust your chair height and work station so you can sit up close to your work and tilt it up at you. Rest your elbows and arms on your chair or desk, keeping your shoulders relaxed.
  • When sitting in a chair that rolls and pivots, don't twist at the waist while sitting. Instead, turn your whole body.
  • When standing up from the sitting position, move to the front of the seat of your chair. Stand up by straightening your legs. Avoid bending forward at your waist. Immediately stretch your back by doing 10 standing backbends.
  • Driving
    • Use a back support (lumbar roll) while sitting or driving in the car.
    • Move the seat close to the steering wheel to support the hollow of your back.
    Standing
    • Stand with your head up, shoulders straight, chest forward, weight balanced evenly on both feet and your hips tucked in.
    • Avoid standing in the same position for a long time.
    • If possible, adjust the height of the work table to a comfortable level.
    • When standing, try to elevate one foot by resting it on a stool or box. After several minutes, switch your foot position.
    • While working in the kitchen, open the cabinet under the sink and rest one foot on the inside of the cabinet. Change feet every 5 to 15 minutes.
    Stooping, Squatting, Kneeling

    Decide which position to use. Kneel when you have to go down as far as a squat but need to stay that way for awhile. For each of these positions, face the object, keep your feet apart, tighten your stomach muscles and lower yourself using your legs.

    Lifting Objects
    • Try to avoid lifting objects if at all possible.
    • If you must lift objects, do not try to lift objects that are awkward or are heavier than 30 pounds.
    • Before you lift a heavy object, make sure you have firm footing.
    • To pick up an object that is lower than the level of your waist, keep your back straight and bend at your knees and hips. Do not bend forward at the waist with your knees straight.
    • Stand with a wide stance close to the object you are trying to pick up and keep your feet firm on the ground. Tighten your stomach muscles and lift the object using your leg muscles. Straighten your knees in a steady motion. Don't jerk the object up to your body.
    • Stand completely upright without twisting. Always move your feet forward when lifting an object.
    • If you are lifting an object from a table, slide it to the edge to the table so that you can hold it close to your body. Bend your knees so that you are close to the object. Use your legs to lift the object and come to a standing position.
    • Avoid lifting heavy objects above waist level.
    • Hold packages close to your body with your arms bent. Keep your stomach muscles tight. Take small steps and go slowly.
    • To lower the object, place your feet as you did to lift, tighten stomach muscles and bend your hips and knees.
    Reaching Overhead
    • Use a foot stool or chair to bring yourself up to the level of what you are reaching.
    • Get your body as close as possible to the object you need.
    • Make sure you have a good idea of how heavy the object is you are going to lift.
    • Use two hands to lift.

    Sleeping and Laying Down

  • Select a firm mattress and box spring set that does not sag. If necessary, place a board under your mattress. You can also place the mattress on the floor temporarily if necessary.
  • If you've always slept on a soft surface, it may be more painful to change to a hard surface. Try to do what's most comfortable for you.
  • Use a back support (lumbar support) at night to make you more comfortable. A rolled sheet or towel tied around your waist may be helpful.
  • Try to sleep in a position which helps you maintain the curve in your back (such as on your back with a lumbar roll or on your side with your knees slightly bent). Do not sleep on your side with your knees drawn up to your chest.
  • When standing up from the lying position, turn on your side, draw up both knees and swing your legs on the side of the bed. Sit up by pushing yourself up with your hands. Avoid bending forward at your waist.
  • Other Helpful Hints
    • Avoid activities that require bending forward at the waist or stooping.
    • When coughing or sneezing, try to stand up, bend slightly backwards to increase the curve in your spine when you cough or sneeze.
    What is acute low/mechanical back pain?

    Acute low/mechanical back pain is a common medical problem. Acute pain is pain that has been present less than four to six weeks. Mechanical means the source of the pain may be in the spinal joints, discs, vertebrae or soft tissues. Acute mechanical back pain may also be called acute low back pain, lumbago, idiopathic low back pain, lumbosacral strain or sprain, or lumbar syndrome.

    What causes low/mechanical back pain?

    A precise cause of low/mechanical back pain can be identified 20 percent of the time. Sometimes, a specific trauma to the back or strenuous activity may cause the pain. However, 80 percent of the time, the specific source of pain is not found.

    It implies the source of the back pain is in the spine and/or its supporting structure. The surrounding muscles and ligaments may become inflamed and irritated.

    Less than one percent of people who develop acute low back pain have a serious cause, such as cancer or infection, to explain their pain.

    What are the symptoms of low/mechanical back pain?

    Most people experience pain primarily in the lower back. The pain may spread (radiate) to the buttocks, thighs or knees. Many people may also experience spasms with mechanical back pain. The symptoms of low/mechanical back pain are generally more noticeable with flexion of the back and when lifting heavy objects.

    Back pain is usually more severe than leg pain (sciatica). Sciatica is usually the result of a pinched nerve, when a protruding disc is putting pressure on a spinal nerve. With sciatica, the pain frequently extends below the level of the knee.

    How is back pain diagnosed?

    A careful evaluation of your medical history and a physical examination will help your health care providers determine if you have mechanical back pain. Then, they will work with you to create an appropriate treatment plan for dealing with the pain.

    If your health care provider has determined your back pain is mechanical, additional testing is not usually necessary. If your symptoms or examination suggest the possibility of infection, malignancy or a pinched nerve, additional tests may be necessary. Additional testing may include blood tests, X-rays, computed tomography (CT) scan, magnetic resonance imaging (MRI), and/or nerve conduction studies.

    How is back pain treated?

    Non-surgical treatment with limited rest, pain medication, and a supervised therapy program is the recommended treatment for mechanical back pain.

    Bed Rest

    Short-term bed red is recommended for patients with severe back pain and muscle spasms. Bed rest greater than 48 hours is rarely recommended. If you have rested in bed for 48 hours, we recommend that you get up and move about.

    Physical Activity

    We recommend early physical activity to promote rapid recovery from back pain. For moderate to mild back pain, the Center for Spine Health recommends maintaining a near-normal schedule from the onset.

    Ice and Heat Application

    Applying heat and ice alternately to the back is helpful to relax the muscles and decrease muscle inflammation. We generally recommend that you apply heat for 20 minutes. Next time, apply ice for 20 minutes. If you find that one application is more helpful than the other, then use only that application. Generally, heat and/or ice should be applied two to three times per day.

    Medications

    If there is a muscle spasm, a muscle relaxant may be prescribed for a short time (3 to 4 days).

    Non-steroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen are frequently prescribed. They serve as analgesics (pain relievers) and as anti-inflammatories (to decrease muscle inflammation).

    Occasionally, if the back pain is severe, you will be given an analgesic that can be taken with the NSAIDs and/or muscle relaxant.

    Physical Therapy

    In many cases, physical therapy is an essential part of acute back pain rehabilitation. It is important that you work with a physical therapist trained in the exercise approach to promote rapid healing.

    The Center for Spine Health encourages active physical therapy to shorten recovery time and return you to work and leisure activities as quickly as possible. Active physical therapy is an exercise program that may require home exercises as frequently as every two hours while you are awake. The exercises generally take about 5 minutes to do and do not require special equipment, nor do you need to go to a gym to do them.

    Passive physical therapy methods may be recommended for short-term use only. Passive methods produce short-term symptom relief, but no lasting improvement occurs. Passive therapy procedures include massage, ultrasound, diathermy, heat and traction. Some patients may also benefit from manipulation.

    When can I return to work?

    We usually recommend that you return to work promptly. If you can not do your regular job initially, it is in your best interest to return to some kind of modified duty (light or restricted duty). Your health care provider can give you a prescription for a limited period of modified work duty.

    It is very common to be afraid to promptly return to work and other activities due to fear of re-injury. The Center for Spine Health specialists know from experience that with proper treatment, the risk of re-injury is very low. It is in your best interest to return to a normal lifestyle promptly. Early mobility has been found to directly result in a more rapid recovery. Maintaining a positive mental attitude is also imperative to a quick recovery.

    What is the outlook for people with back pain?

    The prognosis for complete recovery is excellent. Most people with acute mechanical back pain respond very rapidly to treatment; 90 percent of people with acute low back pain are symptom-free in one to two weeks. Many of the remaining 10% recover within three months. It is important that you maintain a positive mental attitude, continue to engage in regular daily activities, and return to work promptly.

    Recurrences of back pain are common. Continuing your home exercise program may help reduce your risk of another episode of pain.