Oh, That Aching Back

Don’t tango with an elephant. Seems like easy advice to follow, doesn’t it? Yet, as far as your back is concerned, that’s pretty much what you do when--while balancing a large bag of groceries on your hip--you twist down to a child’s car seat, reach over to unlock the harness, and pick up 27 pounds of squirming toddler. It was just such a maneuver that recently landed 42-year-old Mark H. in the office of Duke orthopedic surgeon Lloyd Hey, MD, with severe back pain.

Many people put themselves through similar contortions several times every day. The fact that so many people also suffer from back pain is not a coincidence. Whether it’s caused by back disorders, disc disorders, or injuries to the back (see a list of common back pain culprits, below), back pain ranks second only to headaches as the most frequent source of pain complaints. By some estimates, back pain sufferers ring up more than $90 billion annually in health-care expenses, and account for 33 cents of every dollar spent on U.S. disability claims.

At Duke, Hey and his colleagues take care of patients from across the southeast U.S. and around the world with every sort of painful back condition, from herniated disks to congenital spinal deformities. Hey’s specialty, in fact, is helping patients with serious spinal problems like scoliosis to live normal, healthy lives. But he says that most people with back pain don’t need aggressive treatment so much as a tutorial in responsible spine stewardship.

The human spine is a finely balanced network of bones, ligaments, muscles, and nerves, arrayed along a sinuous series of curves at your neck, upper back, and lower back. It’s an intricate, ingenious structure designed to combine flexibility and stability while absorbing the impact of day-to-day living. When the stresses put on the back exceed its power to absorb them, however, pain is the unhappy result. While discomfort can be experienced in any region of the back, most cases of acute back pain are located in the lower back, or lumbar region, which supports the weight of the upper body.

A variety of factors can raise your risk for back pain, including repetitive lifting, smoking or drinking in excess, a lack of calcium in the diet, osteoarthritis, and depression. Back pain can also be an occupational hazard: Four percent of all nursing assistants and more than one in 10 garbage collectors have at least one bout of back pain per year.

According to Hey, however, the vast majority of back injuries are caused by a simple lack of what he refers to as “good body biomechanics.” Most people move through their lives in ways that invite or exacerbate pain. They exercise little, slouch when they walk, and slump over in their seats. Then they lift too-heavy loads in postures that leave the back unsupported. In fact, people usually aren’t aware of the many ways that they strain their back--until their back lets them know it (see below for back injury prevention tips and pointers for back-friendly lifting).

Mark, the dad who twisted down and hoisted his toddler aloft while juggling a bag of groceries, was a classic case of a back accident waiting to happen: he was overweight and out of shape--wanting to exercise, but between work and family commitments, never finding the time. “The large majority of common back problems would never happen if people at risk would lose weight and learn to reach for things safely,” Hey says.

Most episodes of acute back pain respond well to conservative treatment, which may involve physical therapy, a course of anti-inflammatory medicine such as ibuprofen, weight loss, lumbar support (a corset or brace), and low-impact aerobics. Though some back pain sufferers have found relief with acupuncture, an ancient medical procedure involving the insertion of extremely thin needles at various depths at strategic points on your body, scientific data on the technique’s effectiveness in easing chronic back pain is mixed.

These days, a growing number of people who suffer from chronic pain are seeking out a holistic, body/mind approach to managing their discomfort--the hallmark of Duke’s Center for Integrative Medicine. “Diagnosis is just the first step,” says the center’s Sam Moon, MD, an expert in occupational and environmental medicine who has treated patients with back pain for more than 30 years. “It’s equally important to understand the patient’s beliefs, preferences, and priorities, and to evaluate their risk for future health problems.”

Whether pain is acute or chronic, Moon encourages people with back pain to stay, as he puts it, “cautiously active.” “When people are in pain, they tend to stop moving,” Moon says. “But it’s critical that they learn better ways to move and stay active, as appropriate to their conditions. This approach preserves and enhances overall health and vigor.”

Moon’s colleague Linda Smith, the center’s program director, says that while it’s not always possible to locate and treat the precise cause of back pain, people have more control than they realize over how they experience it. “We want our patients to feel empowered,” Smith says, “not like victims.”

Toward that end, the Integrative Medicine team offers a variety of classes in Mindfulness-Based Stress Reduction (MBSR), both for overall wellness and as a complementary treatment for chronic health conditions. Participants learn how to use meditation, breath work, and hatha yoga to observe and modify their reactions to such stress as pain, work and family pressures and to connect more fully with their inner resources for living and healing.

In severe cases of acute back pain, more aggressive treatment may become necessary. Orthopedic interventions performed to ease back pain include steroid injections (according to Hey, they work “like Drano” to open up inflamed spinal channels and relieve pain) and a procedure known as laminectomy, used to remove bone spurs or disk fragments that protrude into the spinal canal or press on nerve roots within the spine. More severe cases may require fusion, which joins two vertebrae, possibly with the assistance of metal implants, to eliminate painful movement.

Surgery turned out to be just what the doctor ordered for Christy M., a 37-year-old college professor and former championship gymnast who had experienced her back “going out” on occasion for over 10 years. One day, while bending over to tie her shoe, she felt excruciating, incapacitating pain. Diagnosed with a herniated disc, Christy was scheduled for a discectomy, a surgical procedure that removes the damaged disk tissue to relieve pressure on the nerve roots. The results were dramatic: She regained her ability to walk within a day, and continues to grow stronger. “Before I injured my disc, I jogged and worked out regularly, and never needed to go to the hospital,” Christy says. “But without that surgery, I don’t know what I would have done.”

Even when surgery is required, less is sometimes more. New instruments and techniques are being used to minimize the impact of surgery on the body and to ease and expedite recovery. At Duke, orthopedic surgeons have developed new motion-sparing techniques to retain as much flexibility as possible, as well as enhanced-performance fusion technology that helps facilitate an earlier return to athletic activities, especially for younger patients. (The fact that some surgical procedures can now be performed through smaller incisions also has a happy cosmetic result: less visible scars.) Thorough education, support, and follow-up care, as well as expert physical therapy, can help ensure optimum outcomes.

Of course, as with every health condition, prevention is the best course of all. So to keep your back as pain-free as possible, eat right, stay reasonably fit, and take some simple precautions to minimize strain on your spine. And whatever you do, don’t tango with an elephant.

Prevent Pain/Lift Properly

Five Ways to Prevent Back Pain

1. Don’t carry anything extremely heavy or use a supported (rolling) bag.
2. Lose weight. Losing five pounds of weight has the effect of removing 25 pounds of weight from your spine.
3. Exercise regularly, using low-impact aerobic activity and supported stomach crunches. Excessive high-impact exercises such as running may contribute to back pain.
4. Take your vitamins. More than 80 percent of people will experience some form of fracture or osteoporosis during their lifetime, simply because they don’t have enough calcium and Vitamin D.
5. By age 50, have the density of your bones evaluated with a DEXA (Dual Energy X-ray Absorptiometry) scan. If the screening reveals evidence of osteoporosis, immediate treatment can help preserve your quality of life as you grow older.

How to Lift a Heavy Object Properly

The American Academy of Orthopedic Surgeons has developed tips to help you reduce your risk of back pain. Whether you are lifting and moving a person or a heavy object, the guidelines are the same.

• Plan ahead what you want to do and don't be in a hurry.
• Spread your feet shoulder-width apart to give yourself a solid base of support.
• Bend your knees.
• Tighten your stomach muscles.
• Position the person or object close to your body before lifting.
• Lift with your leg muscles. Never lift an object by keeping your legs stiff while bending over it.
• Avoid twisting your body; instead, point your toes in the direction you want to move and pivot in that direction.
• When placing an object on a high shelf, move close to the shelf. Do not stand far away and extend your arms with the object in your hands.
• Maintain the natural curve of your spine; don't bend at your waist.
• When appropriate, use an assistive device such as a transfer belt, sliding board or draw sheet to move a person.
• Do not try to lift something that is too heavy or an awkward shape. Get help.

Common Causes of Back Pain

Muscle strains: Strained muscles, tendons, or ligaments, as well as inflamed joints, may cause pain along the spine.

Spasms: Muscle spasm, a common response to injury, is actually a protective response designed to immobilize the painful area and prevent further damage.

Disc Degeneration: The normal wear-and-tear process that affects all discs throughout the spine. The pain associated with the condition often resolves as the body naturally heals across the worn disc(s).

Osteoarthritis: A degenerative joint condition that affects nearly everyone past age 60. Overloading, injury, and aging can cause deterioration of cartilage, the protective tissue that covers the surface of the joints of your vertebrae.

Sciatica: Pain that may occur in your leg due to inflammation or compression of nerves in your lower back.

Osteoporosis: A condition that causes porous and brittle bones, leading to a gradual weakening of the skeleton and a greater risk for bone fractures that are both painful and debilitating. People older than 50, particularly women, are prone to osteoporosis.

Herniated disk: A condition that occurs when normal wear and tear or exceptional strain causes a disk to rupture. Bulging of disks is common and often painless; it becomes painful when excessive bulging causes fragments of the disk to break off, putting pressure on nearby nerves.

Fibromyalgia: A chronic syndrome that produces aches, tenderness, and stiffness in the muscles and joints where tendons attach to the bones.

Sometimes It’s More Serious

More rarely, back pain can be traced to conditions such as the following.

Spinal Stenosis: A condition often due to arthritis and disc bulging that pinches on nerves going to the arms and/or legs, causing trouble walking, standing, and possibly pain radiating down arms or legs.

Spondylolisthesis: A condition where one vertebra no longer lines up properly on the one below it. It can be a source of back and leg pain, and in some cases requires surgical stabilization.

Kyphosis: Bowing of the back resembling a humpback can result in compression fractures or spondylolisthesis.

Scoliosis: Twisting of the spine; can occur in adolescence or late in life. It is painful and can cause pressure on the heart and lungs.

For more information: Mindfulness-Based Stress Reduction Program