If you have lower back pain, you are not alone. Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States – only headache is more common. Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions.
Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature – the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight. Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the body. Some acute pain syndromes can become more serious if left untreated.
Chronic back pain is measured by duration – pain that persists for more than 3 months is considered chronic. It is often progressive and the cause can be difficult to determine.
Spinal Anatomy
The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord – the delicate nervous system structure that carries signals that control the body’s movements and conveys its sensations. Stacked on top of one another are more than 30 bones – the vertebrae – that form the spinal column, also known as the spine. Each of these bones contains a roundish hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage. Small nerves (“roots”) enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.
Starting at the top, the spine has four regions:
· The seven cervical or neck vertebrae (labeled C1-C7),
· The 12 thoracic or upper back vertebrae (labeled T1-T12),
· The five lumbar vertebrae (labeled L1-L5), which we know as the lower back, and
· The sacrum and coccyx, a group of bones fused together at the base of the spine.
The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.
Common Conditions
Conditions that may cause low back pain and require treatment by a physician or other health specialist include:
Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower lumbar portion of the spinal column.
A much more serious complication of a ruptured disc is cauda equina syndrome, which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the leg due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, metastatic disease, or degeneration of the sciatic nerve root.
Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
Osteoporosis is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine and hips results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis. Caucasian women of northern European heritage are at the highest risk of developing the condition.
Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple “tender points,” particularly in the neck, spine, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).
Diagnosing Conditions
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurological tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.
A variety of diagnostic methods are available to confirm the cause of low back pain:
X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any vertebral misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.
Computerized tomography (CT) is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of low back pain. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures of the back. This diagnostic exam is generally conducted at an imaging center or hospital.
Magnetic resonance imaging (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes – one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.
Bone scans are used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
Common Treatment Methods
Most low back pain can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength to the back, and preventing recurrence of the injury. Most patients with back pain recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.
Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.
Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.
Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulates the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow.
When back pain does not respond to more conventional approaches, patients may consider the following options:
Chiropractic Care: Spinal manipulation is literally a “hands-on” approach in which professionally licensed doctors of chiropractors use leverage and a series of exercises to adjust spinal structures and restore back mobility.
Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.
Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to increased functional impairment.
Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).
Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.
In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia, while others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves.
· Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
· Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
· IntraDiscal Electrothermal Therapy (IDET) uses thermal energy to treat pain resulting from a cracked or bulging spinal disc. A special needle is inserted via a catheter into the disc and heated to a high temperature for up to 20 minutes. The heat thickens and seals the disc wall and reduces inner disc bulge and irritation of the spinal nerve.
· Nucleoplasty uses radiofrequency energy to treat patients with low back pain from contained, or mildly herniated, discs. Guided by x-ray imaging, a wand-like instrument is inserted through a needle into the disc to create a channel that allows inner disc material to be removed. The wand then heats and shrinks the tissue, sealing the disc wall. Several channels are made depending on how much disc material needs to be removed.
· Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
· Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.
Managing Low Back Pain with Exercise and Stretching
Any treatment plan for lower back pain should include an exercise program that will aid in strengthening and restoration of the lower back musculature and soft tissue structures. Depending on the type of injury and the severity, exercises and stretching will widely vary but nonetheless, should be incorporated at some point. It may be effective in certain injuries to begin right away with light stretching, while for other types of injuries it may be best to wait for any swelling or inflammation to subside.
So where do we begin and how do we best determine when a patient will begin exercise? More importantly, what types of exercises and how much. Also, what exercises are best to avoid with lower back pain.
First, acute pain is typically when you want to avoid any exercise at all. There is usually some type of inflammation process occurring at this point, so the best thing would be to rest the back until the symptoms lessen or dissipate. Once the initial flare-up has subsided, it is at that point when mild exercise & stretching may be beneficial (it is strongly advised that you consult with a specialist before initiating an exercise program).
The types of exercises that are encouraged at this sub-acute or chronic stage may slightly vary but these are usually the safest and most effective performed with consistency:
Simple stretches can help loosen your back muscles, warm them up and prepare them for exercise. Even if you don’t exercise strenuously, warming your back up before your day can reduce stress on the muscles and prevent cramps, tightening and pain.
Knee to Chest
Lying on your back, flatten your feet on the floor. Put your hand behind your left knee and pull it towards your left shoulder. Hold for five. Release. Repeat with your right knee to right shoulder. Perform five to six times.
Hug your Knees
Lying on your back, feet flat on the floor, pull both knees to your chest and hug them. Roll gently from hip to hip for a count of five and then release. Repeat five to six times.
Do the Twist
Lying flat on the floor, stretch your arms out to the sides. Bring your knees up to your chest. Gently lower your knees to the floor to the right. Do not push them past the point of tightening. Hold for a count of five and return them to the middle for a five count. Then lower the knees toward the left and hold for a count of five. Perform the twist five times for each side.
Office Chair Rest
Sitting on the chair, put your right ankle on your left knee and lean forward. Hold for a count of twenty and then sit back. Swap ankles and repeat. Do five times for each leg.
Remember when performing stretches that you should never engage in short, jerky motions. It should be smooth and gentle. You should never push beyond the pain or too tight point. Stretching should let the muscles reach a little further, warm them up but not injure them.
Balance balls are also great tools for lower back exercises.
Add back exercises to your regular regimen. Use abdominal exercises to create equal and opposing strength in order to build a strong core.
Bridge
Lying on your back, bend your knees and flatten your feet against the floor. You may want to brace your feet against a wall or a sofa. Lift your buttocks up. Keep your shoulders flat against the ground, but do not push up with your shoulders. Use your buttocks, back and abdomen to hold your body firm. There should be a straight line from your knees to your shoulders. Hold for a count of five and then slowly return to resting position. Repeat six to ten times. You may also perform this exercise by lying on a balance ball and stretching your arms back so that your hands and feet rest flat against the floor. But you should build up to this level of exercise slowly.
Plank
The plank may be performed with an exercise ball or with a stationary object such as a sofa or chair. Lying flat on your back, put your feet up on the balance ball or sofa. Gently pushing upwards with your buttocks, stretch your legs and create a perfect diagonal from your toes to shoulders. Hold for a count of ten and then release. You can actually build this up to sixty seconds of holding. Do not use your neck or shoulders to maintain this position, but your back, buttocks and abdomen. Repeat five times.
Wall Squats
Place your balance ball between your back and a wall. Stand so that you are holding the ball firmly with your feet shoulder width apart. Slowly, bend your legs and move to sit down, as though into a chair and allow the ball to move down the legs. You’re looking to bend your knees at least 45 degrees with an optimal 90 degrees. Hold for a count of five and then rise back to standing. Repeat five to six times. Keep the motion slow and deliberate; use the balance ball to maintain your balance. The point is to use your back and buttocks to maintain your balance and strengthen the muscles there.
Yoga
Yoga has been used for thousands of years to promote health and prevent disease, and many people with back problems have found yoga to provide several benefits, including:
· Relieving pain
· Increasing strength and flexibility
· Teaching relaxation and acceptance
In recent years, researchers have become interested in studying the effects of yoga on treating disease, and studies are encouraging that yoga can be a useful part of the treatment plan for many medical conditions as varied as heart disease, carpal tunnel syndrome, epilepsy, asthma, addiction, and many neck and back problems.
Will yoga help back pain or neck pain?
Although no one treatment works for everyone, many aspects of yoga make it ideal for treating back and neck pain. For example, studies have shown that those who practice yoga for as little as twice a week for 8 weeks make significant gains in strength, flexibility, and endurance, which is a basic goal of most rehabilitation programs for back pain or neck pain.
In addition, the breathing and meditation aspects of yoga induce a “relaxation response” that has been found in many studies to assist people in decreasing their pain. Yoga has also been found to be helpful in the treatment of depression and anxiety that often accompany pain problems.
Is yoga possible for people who aren’t naturally flexible?
Many times those who are not inherently flexible actually benefit from yoga the most. In addition, most yoga poses can be modified for beginners so that everyone can do a version of the poses. Yoga is more than a set of exercises to increase flexibility, however. Different skills are needed for different yoga poses: some help the practitioner gain strength, others challenge balance, and others train attention and concentration.
Is there anyone who shouldn’t do yoga?
Yoga can be safe for everyone, but depending on the medical condition, certain poses may need to be modified or avoided. A couple of examples of patients who may need to avoid certain yoga poses include:
· Patients who have been diagnosed with advanced spinal stenosis should avoid extreme extension of the spine such as back bends in yoga.
· Patients with advanced cervical spine disease should avoid doing headstands and shoulder stands in yoga.
Most of the precautions surrounding the yoga poses can be determined by understanding the specific medical condition, using common sense, and finding a good yoga teacher to assist.
Exercises to Avoid with Low Back Pain
The main point to keep in mind is that any type of activity that causes pain should be stopped immediately. The best exercises to undertake while suffering from back pain are those which do not involve excessive flexion or extension.
Those who experience lower back pain should not be involved in any team or contact sports (such as baseball, football, or basketball) until they feel better. While the cardiovascular activity will certainly help the back in terms of improved circulation, there is no guarantee that another player won’t collide and worsen a back injury. Other exercises to avoid with lower back pain involve sudden movements, such as golfing or gymnastics.
Cycling should be avoided if done for recreational purposes, so those who rely on a bicycle for transportation should only travel as much as necessary and keep at a slow, steady pace. Running should be avoided altogether, since the jarring motion can have an adverse effect on the back. Walking should substitute it for a few days while the back heals, or low impact machines like a stair climber or stationary bike can be used with proper posture. Swimming is also better on the joints than just about any exercise; while it provides plenty of resistance; it also reduces the strain of weight.
Some strength training exercises are also off-limits, including sit-ups and leg raises. Both of these exercises use the lower back extensively, and often, those who are not experienced with these exercises do them incorrectly.
Many experts recommend Pilates, which is designed to stretch out the muscles and promote proper alignment of the spine. While Pilates is an effective way to improve circulation and alignment, it can exacerbate back problems if done improperly.
There are a few guidelines on which specific exercises to avoid with lower back pain, but the general idea is to listen to the body and refrain from overexertion. Exercise is supposed to make one feel challenged but not leave him or her in pain. Low-impact cardiovascular activity combined with light stretching can help relieve back problems, and in time can help improve ones health overall.
Overall, regardless of what type of health professional or self-treatment that is decided upon to undergo for lower back pain, exercise and stretching should undoubtedly be a key component in the treatment and management program.