Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.
Something to Consider When You have Back Pain
Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.
It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.
Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.
Back Pain Red Flags
Here are some red flags that should be considered when back pain is severe, persistent, or associated with other symptoms.
- If you are on a treatment program requiring prolonged ingestion of a corticosteroid or a thyroid hormone, especially if you are past middle age, sudden appearance of back pain that restricts movement might be an indication that an osteoporotic vertebra has collapsed. The location of a vertebral crush fracture can often be determined by applying percussion over a prominent spinous process.
- If you have a history of lung, breast, or prostate cancer and you develop a gradual onset of back pain, or if you have persistent back pain for no apparent reason, you should be tested for bone disease. Some forms of malignancy commonly metastasize to the ribs or the vertebrae, requiring a bone scan or some other special imaging procedure to detect the disease in an early stage.
- Backache can be caused by a kidney infection that may go undetected until an elevation in temperature is discovered. Always take your temperature when you have a backache. If you have a fever, you should always see your family physician, regardless of what you think might be causing your backache. Any persistent backache that defies diagnosis should undergo testing and observation in a search for such elusive diseases as ankylosing spondylitis or rheumatoid arthritis.
- Kidney stones can cause acute back pain. Unlike mechanical-type back pain that is relieved by rest and intensified by movement, the referred pain of a kidney stone produces pain that will not allow you to rest or sit still. If you have the misfortune of experiencing back pain that causes you to squirm about or roll around on the floor, you should go to a hospital emergency room as soon as possible.
- Pain, numbness, and other symptoms radiating down one or both legs, or weakness in one leg or foot, especially when associated with back pain, would be a red flag indicating possible encroachment upon spinal nerves. Such symptoms could be caused by disk herniation, osteophyte formation, or some other pathological process.
- Sudden appearance of constant and severe leg pain that is not associated with back pain, or cramping leg pain that occurs only when you walk and is relieved by rest (intermittent claudication), might be an indication of diseased arteries. Your family physician might want to refer you to a vascular specialist in order to differentiate vascular claudication from neurogenic claudication caused by spinal stenosis.
- Loss of bladder or bowel control (especially urinary retention) that is associated with back pain or numbness in the perineal or saddle area of your pelvis is a medical emergency (cauda equina syndrome) requiring the immediate attention of a neurosurgeon. Such symptoms can be caused by a lumbar disk protrusion that has entered the spinal canal.
Diagnosing Back Pain
Although an x-ray exam is not often indicated (depending upon your medical history) when acute back pain occurs, your doctor might order an imaging study if symptoms persist longer than a month. A plain x-ray image can be helpful in finding a structural problem, such as spondylolisthesis, that might be causing back pain; it might also detect bone disease, an abdominal aneurysm, or some other problem that might be causing non-musculoskeletal back pain. When there is a red flag involving spinal nerves, an MRI study might be needed to look for nerve root impingement or disc herniation. CT-myelography might be ordered in the case of spinal stenosis or cauda equina syndrome, and so on. An appropriate specialist will order an appropriate testing procedure. In most cases, a good physical exam and a detailed case history by an astute clinician will provide a diagnosis that will often be confirmed by special studies.
Generally, non-musculoskeletal back pain referred from an internal organ is characterized by pain that is not affected by movement, percussion, and other mechanical testing procedures. Back pain complicated by neurological symptoms, such as loss of reflexes, localized muscle weakness, muscle atrophy, and other signs of progressive nerve damage, may be an indication of massive herniation of an intervertebral disk.
Barring the medical emergency of a cauda equina syndrome, any recommendation for surgical excision of a herniated disk would warrant taking time for a second and third opinion. Surgery can often be avoided when time is combined with periodic evaluation by a physician who can watch for progressive neurological signs that indicate an unquestionable need for surgery.
Basic Self-Help Measures
When the U.S. Department of Health and Human Services published Acute Low Back Problems in Adults in 1994, it advised that “The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost. As an option, patients may be taught self-application of heat or cold to the back at home.”
Here are some basic self-help measures that anyone can use safely and effectively to relieve symptoms and to buy the time needed for recovery.
Cold and heat: As a general rule, it’s best to use cold applications during the first 24 to 48 hours after an injury─about 20 minutes at a time several times during the day. Cold constricts blood vessels and reduces swelling. When an injury is severe enough to cause swelling in deep tissues, early application of heat might increase pain and swelling by dilating blood vessels and drawing blood into the injured tissues. While it’s unlikely that significant capillary bleeding occurs in simple, uncomplicated back strains, many physicians routinely recommend cold applications during the first 24 hours as a safety measure and to relieve pain by numbing the tissues.
When back pain is not severe, it probably makes little difference whether you use heat or cold; you may try using brief applications of each and then use whichever feels best. Heat applied for 20 or 30 minutes will often provide soothing relief by relaxing spastic muscles. If heat seems to increase pain or cause a throbbing sensation, you should discontinue use of heat and use cold applications for at least two days before trying heat again.
A gel pack that can be cooled in a freezer or heated in a microwave oven can provide a convenient source of heat or cold. Such packs can be strapped to the back to permit movement around the house; they should always be wrapped in fabric to prevent tissue damage caused by excessive temperature.
Rest: When acute back pain occurs as a result of injury, you may have no choice other than to rest in bed the first day or two. But the sooner you begin moving around, the better. Unless you have sustained a spinal fracture or a herniated disk, it’s never a good idea to stay in bed longer than a couple of days. Prolonged bed rest─longer than four days─can lead to weakness and debilitation.
When you are resting in bed, placing a pillow under your knees will relieve strain on your lower back by taking tension off hip flexors (psoas muscles) that tug on the lumbar spine. You can relieve tension on hip flexors and get the added effect of traction by lying on the floor and draping your legs over the arm of a sofa. If you don’t have leg pain caused by nerve root impingement, don’t be afraid to move around the house, even if you have to grunt and groan to do so. Even though movement may be painful, the pain you feel will prevent excessive movement and will not worsen your injury. Use a walker or a pair of crutches if necessary. A simple wrap-around velcro back support might help when standing or walking. A behind-the-back cushion to maintain the normal lumbar curve while sitting might also be helpful.
Medication: When you have uncomplicated musculoskeletal back pain (without sciatic nerve root compression), you won’t often need prescription medication to relieve your pain. Over-the-counter medication such as Tylenol (acetaminophen) will usually provide adequate pain relief. But do not continue use of such medication for longer than about a week at a time. In most cases, the acute pain of a nonspecific back problem will subside after a few days. If pain persists unrelieved, see your doctor. Prolonged or excessive use of acetaminophen, aspirin, or any of the nonsteroidal anti-inflammatory medications (NSAIDs) can have serious side effects. Use medication only as needed if a cold pack or a hot pack does not relieve the pain enough to allow you to lie down and sleep at night.
Exercise: Avoiding bed rest that lasts for longer than a day or two will help reduce the weakness and stiffness caused by back injury. But after two to four weeks of restricting normal activities to relieve mechanical-type back pain, you should begin doing a little exercise to help regain lost strength and mobility─without placing compression or leverage on the lumbar spine and without contraction of hip flexor muscles that tug on lumbar vertebrae. Care must also be taken to avoid forced or excessive flexion or extension of the lumbar spine. Here are two starting exercises that can be done safely and comfortably by anyone.
- Get down on your hands and knees. Arch your back up and down several times with slow, deliberate movement. This alternate contraction of abdominal and back muscles with flexion and extension of your spine will loosen spinal joints and tone muscles supporting your spine.
- Lie on your back with your knees bent, your feet flat on the floor, and your arms at your sides. Lift your body from the floor so that your weight is supported by your feet and your shoulders to form a bridge. Work up to 12 to 15 repetitions. You can increase the resistance of the exercise in a progressive manner by placing a little weight over your lower abdomen and holding it in place with your hands.
Healing is a matter of time, but it is sometimes also a matter of opportunity.
— Hippocrates, 400 B.C.