Aching Back? Education and Prevention are Top Priorities

It's as common as the common cold, and a chief reason people make appointments with their family doctors. It hobbles millions of us every day - weekend warriors, who try to cram all their recreation into one or two days a week; people who lift a heavy bundle incorrectly; or someone who twists his back doing something as simple as bending, reaching or getting in or out of a car. It's the No. 2 reason for absenteeism at the workplace.

"Low back pain is the most common presenting complaint patients have when they visit their primary care physician," says Raj D. Rao, MD, Associate Professor and Director of Spine Surgery in the Department of Orthopaedic Surgery at the Medical College of Wisconsin. The pain can be excruciating, but the good news is, it's usually self-limiting, he says.

"Most of the time the pain resolves in a matter of days or a few weeks. By the time I see patients, it's because their pain persists longer than six to 12 weeks, and they experience neurological problems in their legs in addition to back pain." Those cases are relatively uncommon in the universe of low back sufferers, he notes.

And although he is an orthopaedic surgeon, Dr. Rao is a fervent advocate of conservative treatment, with surgery performed only as a last resort when non-invasive methods fail to provide relief.

Causes - Simple and Complex
What causes this widespread scourge of low back pain? Dr. Rao divides them into two major categories:

• Simpler causes - These typically involve the muscles and other soft tissues around the spinal column. These cases are the most prevalent, and they are the cases that usually resolve quickly.
• Complex causes - These are rooted in the actual structures of the spine - the five vertebral bones that constitute the lumbar (lower back) spine, the discs that function as shock absorbers and allow for motion of the spine, and the facet joints that stabilize the vertebrae, among others.

The episodes arising from complex causes may require more time and, in some cases, surgery. These can arise from bulging or herniated discs, in which part of the disc, under pressure, pushes out from between the vertebrae. (This used to be called, inaccurately, a "slipped disc.") Discs can also deteriorate, primarily because of aging, but also from trauma.

Other complex causes include spinal stenosis, a narrowing of the spaces in the spine that results in pressure on the spinal cord or nerve roots, causing pain. It can be caused by age-related degenerative arthritis, or some patients might be predisposed to such problems because of a congenitally reduced space for the nerves.

"Almost every person will have at least one episode of low back pain at some time in his or her life," the American Academy of Orthopaedic Surgeons' Web site says.

Why do so many of us experience low back pain? With the aging of the population, spines start to deteriorate. Rising obesity rates may also contribute: Recently, the North American Spine Society noted that 44% of people seeking treatment for back problems were obese, an increase of 67% over the last five years.

"Obesity can be a factor in low back pain," Dr. Rao says. "People who carry extra weight do put an additional burden on the low back, which already bears the brunt of body weight. Among those with a pendulous abdomen, the body's center of gravity shifts to the front, which means the back muscles have to work even harder and get fatigued more quickly, which triggers pain."

Treatment Begins With Education
For patients with routine, simple back pain that arises from the soft tissues surrounding the spine, Dr. Rao recommends "a multifaceted, multipronged approach" - which can also help prevent future painful episodes. It's simple, but it requires a firm commitment from the patient. "Patients need to be educated about what's causing their back problems and learn how to prevent them," he says. "They need to understand where a majority of their back pain originates, and get a good feel for the factors that may contribute to their pain.

"When patients are educated about what triggers their back problems," he notes, "it takes away their apprehension and gives them reassurance that their problem doesn't have to come back. Many patients worry that back pain means something dangerous, or that it could lead to paralysis or irretrievable nerve damage." This education could come from the patient's family physician, orthopaedic surgeon, physical therapist, or from books or online sources.

"Patients must gradually increase their daily activities and progressively retrain their back muscles with daily stretching and exercises," Dr. Rao says. It's important to learn the correct way to bend and lift, and to avoid postures that stress the back. These are best taught by a physical therapist, says Dr. Rao, who works closely with a team of rehabilitation physicians and therapists. Patients need to incorporate an exercise routine into their daily lives - walking, yoga, swimming, bicycling or similar activities, he says.

Beware of Exotic Treatments
And Dr. Rao has a word of caution for patients who chase after the newest, often exotic treatment options for their pain: "Back pain has been around since the ancient Greeks and Egyptians. Throughout history and continuing today, 'new' treatments have been touted as the latest and greatest. I recommend caution with all of these so-called new treatments unless they've been proven to be successful over a three- to five-year period," he says. These can be a waste of money and even be harmful, he warns.

At Froedtert & The Medical College, Dr. Rao and his colleagues continue to research new methods for treating stubborn cases of low back pain that involve nerve problems with the legs, or pain that won't yield to conventional, conservative treatments.

"We're a very productive research center," he says, with their findings being published in medical journals and their work included in medical textbooks. Recent research has focused on materials used in spinal fusion surgery and their effects on both the affected level of the spine and the adjacent levels. Other research concentrates on stimulating and using patients' own cells to build bone-forming cells to improve the success rates of spinal fusion.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.