Back Pain Overview

Studies show that at some point in life, 80 percent of Americans suffer back pain bad enough to require medication or a visit to a health professional. For about 85 percent of people who lament, “Oh, my aching back,” lower back pain strikes once, slowly goes away over a few months, and returns only occasionally, if ever.

But around 15 percent suffer chronic lower back pain that persists or recurs for years. When it comes to pain complaints, lower back pain is second only to headache. It’s the nation’s number two cause of lost school and work days (after colds and flu). Bad-back health care and lost productivity account for about 35 percent of payments made under worker compensation programs, and cost the nation an estimated $24 billion a year.

Until the last decade, the experts were convinced that backs went bad because of structural problems, and doctors and chiropractors spent a great deal of time poring over x-rays and magnetic resonance imaging (MRI) scans trying to pinpoint the problem. Structural problems can, indeed, cause pain because your back is remarkably complicated.

Your “backbone” is not a single bone, explains family practitioner Anne Simons, M.D., an assistant clinical professor of family and community medicine at the University of California’s San Francisco Medical Center. It’s actually 33 bones (vertebrae, singular: vertabra) irregular donut-like structures, most of which are separated by flexible cartilage rings (disks) that act as shock absorbers. The vertebrae are divided into five groups: Your neck contains seven cervical vertebrae, your upper back, 12 thoracic vertebrae, and your lower back, five lumbar vertebrae. Five fused, disk-free sacral vertebrae run through your buttocks. And your lowest four vertebrae are fused to form your tailbone (coccyx). Your back’s alternating bone-cartilage arrangement allows amazing flexibility of movement. But that flexibility comes at considerable cost—vulnerability to injury, whose roots reach deep into our evolutionary past.

The vertebrae-disk arrangement evolved to support animals that walked on four legs. When our ancestors began standing on two legs, they gained a tremendous evolutionary advantage—their hands were suddenly free to manipulate tools. But life on just two legs also placed enormous strain on our back vertebrae. When your stand upright, your vertebrae are not in the center of your body, but toward the rear, and constantly being pulled forward—and out of alignment—by the unequal weight distribution around them. Add, gravity, falls, other injuries, and big bellies, and you have the back vulnerability the continues to plague us. Your back’s most vulnerable area lies just above your hips in the lumbar vertebrae of your lower back. Many people consider “back pain” and “lower back pain” synonymous.

In addition, starting around age 30, your disks begin to lose some of their resiliency. They become dehydrated, and lose some of their cushioning ability. By age 50, almost everyone has significant disk degeneration.

Finally, your vertebrae are not stacked on top of one another like a flagpole. They meander back and forth in a series of curves. There is no such thing as “ideal” back curvature. Everyone’s back is different.

Structural problems that can cause back pain include:

• Vertebral alignment problems. Injuries, pregnancy, obesity (particularly a “beer belly”), or years of wear and tear can pull your back vertebrae out of alignment. Chiropractors specializes in re-aligning back vertebrae, which is why chiropractic is a popular treatment for back pain (see Chiropractic below).
• Muscle problems. Overuse or sudden twisting can injure the muscles that run up and down your back. In addition, if your abdominal and/or lower back muscles become weak, your vertebrae may shift out of alignment, causing pain. Strengthening these muscles—and exercise in general—is key to treating back pain.
• Nerve problems. Muscle weakness or other problems can also pinch the nerves that emanate from your spine (see SCIATICA below).
• Disk rupture (Slipped disk, herniated disk). The cartilage disks between your vertebrae can break open, spilling their jelly-like filling.
• Other causes. These account for an estimated 15 percent of back problems.

But since the 1980s, major holes have developed in the “structural theory” of back pain. The initial critique came, ironically, from chiropactors, whose founder, D.D. Palmer’s postulated that back pain (in fact, all disease) is caused by vertebral misalignment. The problem was that Palmer’s misalignments (subluxations) could never be seen on x-rays, and when chiropractic manipulation produced dramatic relief of back and neck pain, before-and-after x-rays rarely showed any change in vertebral alignment. Modern chiropractors have largely abandoned Palmer’s notion of vertebral misalignment, and now maintain that chiropractic adjustment normalizes the motion of the vertebrae as they move against one another. Very subtle changes in vertebral motion can have profound impact on the nerves that run through them, increasing or decreasing bioelectrical energy transmission by as much as 50 percent.

Then in 1994, a landmark MRI study by Michael Brant-Zawadzki, M.D., a radiologist at Hoag Memorial Hospital in Newport Beach, California, showed that many people who don’t have back pain do have significant vertebral misalignment, bulging disks, and even evidence of previously ruptured disks. It seems that the more science learns about back pain, the more mysterious it becomes. Some seems to be caused by structural problems. Some is not. Quite often, it’s impossible to determine what causes it.

Mainstream medical treatment of back pain has also been transformed. Until the 1990s, M.D.s advised extended bed rest, pain-relieving drugs, and often surgery. But many studies have shown that bed rest often makes back pain worse, and that surgery is rarely necessary. Today, most mainstream physicians recommend a short course of pain medication for a day or two, and possibly a little time in bed (two days at most), and then a return to normal activities as quickly as possible, with back strengthening exercises, among them, yoga. Increasingly, mainstream doctors also refer back-pain sufferers to chiropractors and acupuncturists.

If you have back pain, take heart. With conservative home treatment—a little pain medication, a little rest, and then a rapid return to normal activities, with exercise—it almost always clears up fairly quickly:

• Canadian researchers followed 206 people with back pain who were treated by family doctors. More than half recovered in two months. Only 10 percent reported pain after one year.
• In a study of 263 back-pain sufferers treated by family doctors, Dutch researchers found that over six months, “all aspects of suffering caused by low back tended to diminish.”
• Former back-pain sufferer Louis Kuritzky, M.D., a clinical assistant professor of family medicine at the Unviersity of Florida in Gainesville, agrees: “When treated conservatively, about 90 percent of people substantially recover within a few months.” So hang in there. You may be in pain today, but you’ll suffer less tomorrow.

One final note: Back pain is so common, that just about everyone has a story about what worked for them, or for someone they know. But the fact is, there is no single path to a pain-free back. “Just as no pair of shoes feels comfortable to everyone,” Dr. Simons says, “no single approach to back care eliminates everyone’s pain. Don’t let anyone talk you into anything. Sure, listen to your friends. Some of their ideas may help you. But don’t assume that what works for them will work for you. Focus on your own back pain, and follow the course that brings you relief.”

Red Flags

consult your doctor immediately if develop:

• Unrelenting back pain that interferes with sleep.
• Back pain that does not begin to improve within two weeks despite good home treatment.
• Back pain with any of the following: fever, leg weakness, bladder or bowel problems, abdominal pain, a history of cancer, unexplained wieight loss, or any recent abdominal surgery.