Why Your Back Hurts
"I ache in the places where I used to play," Leonard Cohen wrote, and most of us have to agree. Of the 80 percent of Americans who experience back pain, most are women between 45 and 64. And one of the spots likely to creak is the lower back, near the low-rise belt line. This is caused in part by aging joints, but many of us also get weaker and more sedentary over time. So when we take on an intense activity — from a new sport to rearranging the furniture — we can damage the vertebrae near the waist, which bear most of our weight.
Back pain can be sharp or dull and can occur slowly or suddenly. Most back flare-ups improve in a week and are all but gone in six to 12 weeks, according to Daveed Frazier, MD, assistant clinical professor of orthopedic surgery at St. Luke’s-Roosevelt Hospital, a Columbia University affiliate in New York. But even easily remedied backaches usually return, and about 10 percent of those who experience them end up with chronic pain. Fortunately, there is plenty you can do to help yourself. The exercises used to treat back problems also help prevent them, so it’s worth the effort to build strong core muscles now — and there’s the bonus of flatter abs.
Most back pain stems from simple muscle and joint strains, yet structural problems, such as herniated discs, are common. Discs, those spongy cushions between the rings of spinal vertebrae, keep them from rubbing together when you move, yet also allow you to bend. Discs are made mostly of water, and they get dryer and flatter as we age and are less able to absorb the effects of sitting, slouching, exercising, heavy lifting, and falling.
Without enough cushioning, the vertebrae can rub against each other and on the nerves of the spine. If the discs get pushed too much, they bulge. Often it’s the lower discs that become herniated and press on a group of nerves at the base of your spine that form the sciatic nerve. This can cause sciatica, a throbbing or stabbing pain that radiates down into your leg.
A disc that bulges can also cause sudden incontinence and weakness or numbness in the legs; if either of those conditions occurs seek emergency treatment.
Smoking increases our risk of back problems, probably by reducing the nutrition flowing to the discs that help keep them healthy. Being overweight also puts strain on your back.
We’ve Got Your Back
When you hurt, the last thing you need is a headache from trying to navigate the maze of conflicting information on back pain: "A lot of the information out there is just plain wrong," Frazier says. The following guide is not a substitute for a consultation with a doctor, but it is a resource for managing your care and landing back on your feet.
Step 1: Determine the Cause
Can you point to a twist, torque, or tumble you took shortly before the pain set in? If so, you may have a simple sprain or strain, with swelling that will ease in a few hours or days. If there is no obvious reason, the most likely cause of midlife pain is osteoarthritis, degenerated discs, and weak core muscles supporting your spine. For a clue to the cause, sit or lean forward. If your pain improves, it could be spinal stenosis, a narrowing of the spinal canal that puts pressure on the nerves. If the pain is worse after sitting or when bending forward, it could signal a disc problem.
Step 2: Try Home Remedies
These self-care basics may help during the first 48 hours.
- Rest. Try lying on your back with a pillow under your knees to take the pressure off your lower back.
- Take over-the-counter anti-inflammatories unless you have a health condition that precludes them.
- Apply ice compresses to reduce swelling. Lie down and place an ice pack or a bag of frozen peas wrapped in a thin cloth or paper under your back. Apply for 15 minutes, and repeat hourly.
- If ice doesn’t help, swelling is probably not the main problem. Try a heating pad or warm bath to improve circulation and speed healing.
- If ice or heat seems to be working after two days, continue it.
- Sleep on your side with a pillow between your thighs or on your back with a pillow under your knees.
- Don’t lift anything heavier than 10 pounds — really. Weigh your handbag. Your back needs a break.
Step 3: Get Moving
Rest, the old prescription for back pain, actually makes you stiffer and weaker all over. So after 48 hours — or sooner if you’re feeling better — you can ease back into activity, even if it’s only a little stretching or walking.
- Avoid twisting, which could cause another flare-up.
- If stretching and gentle movement are still painful, get in the tub (or a pool) and stretch in warm water, which loosens the muscles and provides support.
- Continue anti-inflammatories, warm baths, and the heating pad as needed.
- Keep exercising, even when your back gets better.
Step 4: If the Pain Doesn’t Ease, Call a Doctor
If you’re not noticeably better in 48 hours or completely better within a month — or if this isn’t your first bout with back pain — consult a doctor. Back pain can signal a disc herniation, spinal arthritis, or underlying medical conditions such as a kidney infection or cancer.
Step 5: Ask Your Doctor for a Prescription for Physical Therapy
Think of it as getting a personal trainer and massage therapist for the price of a co-pay. "Evidence supports the idea that the earlier the intervention by a physical therapist, the fewer visits needed and the quicker the recovery," says Connie Hauser, DPT, a member of the board of directors for the American Physical Therapy Association. Physical therapy focuses on assisted stretching and strengthening to help you build a resilient and balanced core, manual therapy and massage to relieve tightness, guidance on moving properly, and sets of at-home exercises.
Step 6: Consider Alternative Therapies
Can herbs and spinal manipulations ease your aching back? "Generally speaking, we lack the kind of research we need and want, which is frustrating when you’re trying to decide about using any of these approaches," says Tracy W. Gaudet, MD, director of the Duke Center for Integrative Medicine at Duke University, in Durham, North Carolina. But she adds, "Lack of research doesn’t mean it won’t be helpful." In fact, more than 200 million Americans head to a chiropractor, massage therapist, or acupuncturist for back or neck pain. Gaudet recommends first asking your doctor whether an alternative therapy could cause harm, and if not, giving it a try. If you don’t get some relief after two to four weeks, however, move on; it shouldn’t take longer than that to see results.
Chiropractic treatment is now so common that many people no longer call it alternative — although researchers and your insurance company probably do. To date, there is some evidence that spinal manipulation, the most popular chiropractic treatment, works for low-back pain. If you want to try it, make sure the chiropractor you choose is a member of the American Chiropractic Association (amerchiro.org) or is on your insurance company’s provider list. Chiropractic treatment is not recommended for patients with osteoporosis or those who experience numbness, tingling, or pain in a leg or foot, which can signal nerve damage.
There is some good if not definitive data that acupuncture, the Eastern system of adjusting your body’s flow of energy (chi), is effective, according to Gaudet. The treatment may not relieve a sudden flare-up in your back, but repeated sessions have been shown to ease chronic pain.
Massage topped the list for relieving pain and keeping patients moving in a major review of dozens of studies of massage, acupuncture, and chiropractic spinal manipulation. Kneading the muscles may improve blood flow and reduce tension in the body and the mind, providing enough pain relief to allow people to be more active. Find a practitioner experienced in treating back pain. Massage is generally safe, but women with osteoporosis should talk to their doctors first.
Earlier this year, researchers at the University of Toronto concluded that two herbal supplements are likely to provide relief for back pain when used briefly to treat flare-ups. Devil’s claw extract provides pain relief when taken at a daily dose of 50 milligrams of the effective ingredient, harpagoside. And a 60-milligram dose worked as well as Vioxx (an effective pain-relief drug that was banned because of increased cardiovascular risks). White willow bark — which contains salicin, an ingredient in aspirin — was comparable to Vioxx in reducing pain when taken at a dose of 240 milligrams daily. The only side effects associated with these herbs were mild stomach complaints. Neither should be taken with medications such as anti-inflammatories without consulting a doctor.
CAVEAT: A recent Harvard study showed that patients who used alternative care for acute pain did not recover faster or better than those who used conventional care. Most patients in both groups recovered; however, the sufferers who received alternative treatments were happier with their care. The bottom line: Whatever helps relieve your pain has the bonus effect of keeping you more active and able to prevent future problems.
Step 7: Use Your Head
"Stress can show up as muscle spasms and muscle imbalance," says Brian Hainline, MD, author of Back Pain Understood. This can speed up disc degeneration. Hainline recommends stress-relief exercises to reduce back pain. He also cites depression — another health condition that often strikes women in midlife — as an example of the part the mind plays in recovery from pain. He adds, "It is a virtual certainty that chronic pain cannot be treated successfully in people with major depression until the depression itself is treated successfully." Fear of pain can also bring on more pain. "People who have been in pain for a long time move as if they are braced, which is psychological and physical," Hainline says.
In a recent review of research on the subject, Duke University scientists concluded that counseling, relaxation training, hypnosis, and biofeedback worked better than traditional treatments. So if your pain is unrelenting, mind-body therapies are certainly worth investigating and, according to Gaudet, are safe and once learned can be done on your own. A good place to start is Healing Back Pain: The Mind-Body Connection, by John E. Sarno, MD.
Step 8: What to Do When Nothing Works
When you’ve tried everything else for at least a few months with no results, should you resign yourself to surgery? "Most people with back pain should not have surgery," Frazier says. In fact, it is appropriate in only a small percentage of cases, he says — for people with sciatica or nerve damage.
For the rest, surgery is often ineffective at relieving pain. Even if your doctor advocates it, get a second opinion. If you do decide to go ahead, explore the surgical options. There are vertebrae fusions (a common procedure in back operations, which have been improved but can still cause future problems). And there are artificial disc replacements. (Replacements are a relatively new procedure, and even among surgeons there is controversy about their use. They may hold promise but don’t yet have a track record.)
Originally published in MORE magazine, November 2007.