Help for the Sufferers of Those Aching Backs : Research Suggests That Shorter, Not Longer, Periods of Bed Rest May Provide Pain Relief
You’re slightly bent over--picking up a pencil at your office or even a leaf in the yard--and, suddenly, you feel a paroxysm of pain in your lower back, almost as if somebody had hit you with a sledgehammer.
Then again, it might not hit immediately. The pain could start six or eight hours later--when you can’t even remember what might have caused it. It lasts for days, disrupting your sleep and making you wonder if your back has been weakened for life.
If this has not happened to you or someone you know, you may find it difficult to imagine that the weight of a pencil or a leaf could inflict this kind of disabling injury. It can, though, and this has nothing to do with the weight of the object, per se.
Awkward Position Blamed
Rather, the cause was the awkward position you put your back in at the time. That positioning played into the hands of the bizarre biomechanics of human beings--walking upright. Hurting yourself this way depends on torque and torsion on the spine, not necessarily on what, if anything, you are lifting.
But if you have experienced this, no one needs to tell you how much it hurts. You are one of millions of people for whom low back pain is possibly the key agony of contemporary American life. Surveys of why people visit their physicians have concluded that low back pain is second only to the severe cold as a reason people go to the doctor.
Now, a new study of treating low back pain has concluded that one of the oldest standbys--a week or two of bed rest--is no more effective than a day or two in bed.
In 80% of such cases, physicians interviewed by The Times agreed, low back pain amounts to nothing more than slight muscle trauma--like a sprain or a pull--that will resolve itself within a few days. Future occurrences may often be averted by exercises to strengthen the muscles of both the back and the abdomen. Yet in some uncalculated minority, the first low back pain episode sets the stage for years of intermittent hurting, with the original injury repeated again and again.
Difficulties in Treatment
For doctors, treating low back pain can be like walking across a minefield. What can blow up in the doctor’s face are cases of what appear to be garden-variety low back pain that really involve far more serious problems--including major infections and cancer--as well as the unfortunately common patient who is trying to build a financially lucrative case for a worker’s compensation settlement. There is always the possibility, too, there may also be a true spinal injury.
Surgery--once performed on tens of thousands of people a year--has come under increasing question in recent years for most back ache. Operations should be reserved, orthopedists now agree, primarily for cases where there has been provable damage to the vertebrae themselves or the spinal discs--which act as a cushion between the vertebrae, enabling the back to change position.
And with the newly completed study, a principal outpatient standby--prolonged bed rest--is apparently to be consigned to the same discredited status as another former principal treatment--putting someone with an aching back in traction.
“I think the only thing that happens when you put people in traction is the doctor knows where they are,” quipped Dr. Ethan Allen, of Los Angeles, who, because he was trained in osteopathy, has had no shortage of contact with back pain patients.
But Allen and other back pain experts know the problem is no laughing matter--especially for patients who have it and, because the reasons for back pain often are invisible in X-rays and other diagnostic tests, can’t get friends, relatives, employers and their doctors to believe it hurts as much as it really does.
Like the injury itself, a profile of back pain in the United States can be staggering. According to a variety of estimates by government agencies and private researchers, 60% to 80% of Americans experience low back pain between the ages of 25 and 69. At any given time, more than 10% of Americans have reported a three-day episode of low back pain within the previous 12 months. In 80% of those cases, the pain will go away on its own in less than two weeks, requiring little more than avoiding stress on the back and pain relief with over-the-counter products such as aspirin, acetaminophen and ibuprofen.
Sufferers miss about 93 million days of work every year, consuming $5 billion in health-care benefits--or, as a recent profile of back pain in a medical journal noted, $25 for each person in the country. By some estimates, as much as 50% to 70% of back pain is not necessarily imagined, but precipitated by psychological factors.
There are still about 300,000 back pain operations a year and, in people under 45, low back pain limits physical activity more than any other cause.
Doctors generally agree that taller people are at more risk of low back pain than shorter individuals--because longer spines are more susceptible to unusual stresses. Often, the incident that brings on low back pain can be traced to a person having been bent forward slightly at the waist, simultaneously turning his or her shoulders to one side so the spine is twisted. This combination of forces puts dangerous torque on the spine so even a simple maneuver like picking up a pencil from a chair can cause an injury.
Prevention can be as easy as paying close attention to the loads you put on your back. Lifting heavy objects is also a key cause and experts overwhelmingly agree that not only should picking things up be done by bending the knees and lifting from a squatting position--rather than by bending at the waist--but the items to be lifted should be held close to the abdomen, not supported away from the body with the arms.
Surprisingly, perhaps, noted an analysis of back problems published earlier this year in the journal American Family Physician, if an object being lifted is held 14 inches from the spine, the effective load on the back is 15 times the actual weight of what you are picking up.
The back becomes more vulnerable to injury as we grow older because the inherent limitations imposed by evolution to standing upright mean that, even in a healthy person, tissue and bone in the back begins to break down by the time a person is 35 or 40. While some physicians believe men are more susceptible to back pain than women, most doctors agree the two sexes are equally at risk.
There is disagreement among physicians over whether overweight people are more prone to low back pain, but doctors agree losing excess weight is a good idea, even if it does not directly reduce back injury potential.
Once a low back injury occurs, treating it can pose a problem for physicians. First, a doctor must rule out any of the more dire diagnostic possibilities, like a ruptured disc, cracked vertebra, degenerative bone disease, cancer or infection. “That’s something that is always hanging around the backs of our minds,” said Dr. J. Donald Thomas, director of the occupational medicine center at Huntington Memorial Hospital in Pasadena.
Often, a patient will describe a sharp pain that radiates downward into the buttocks and possibly even down a leg--the phenomenon often called sciatica because it emanates from the sciatic nerve.
Treatment can include pain relievers, rest and the use of strengthening exercises for the back and abdomen. A few specialists also maintain that the value of strengthening exercises is unestablished, but there is agreement that an exercise program can’t really hurt and may help avert future back pain episodes.
The most common exercises, Thomas and Allen agreed, involve lying on the back and doing what are called pelvic tilts-- the pelvis is rotated so the normally curved lower back comes in contact with the surface you are lying on. The same effect can be achieved while standing or walking, Allen said, by simply sucking in the stomach.
Leg lifts in which the thigh is drawn up toward the chest while the knee is bent are also effective.
Also helpful is changing the way you sleep. Ideally, sleeping on your back on a hard mattress is best, with your knees slightly flexed--perhaps by tucking a pillow under your legs.
Spinal manipulation as practiced by osteopathic physicians and some therapy offered by chiropractors has often proven of at least some benefit in low back pain cases.
Brief Bed Rest
Until recently, bed rest has been an integral part of the treatment regimen, with physicians commonly ordering five to seven days--and even as much as two weeks--of inactivity lying flat on the back in bed. But aside from the fact that researchers have long recognized that patients don’t comply very well with those orders because such periods of inactivity are boring, researchers have now found that a brief bed rest prescription--for two days or so--is just as effective as longer periods.
That was the conclusion of a team of doctors at the University of Texas Health Science Center in San Antonio and the Seattle Veterans Administration Medical Center, who published their study last week in the New England Journal of Medicine. The study involved 203 patients who sought treatment at a clinic for medically indigent patients. They were divided roughly equally between treatment with two days of bed rest and seven days.
Patients ordered to bed for two days missed 45% fewer days of work than those with longer bed rest, but they recovered from their injuries just as completely. “I was interested in back pain because it’s so common and it’s such an expensive problem,” said Dr. Richard Deyo of Seattle, who headed the research team. “My perception is that doctors and patients are both frustrated with how back pain is managed.
“For patients, the frustrations are from the fact that doctors don’t explain to them anything about what might be going on or what the prognosis will be. I think patients are worried that this will be disabling and want some reassurance about what is likely to happen to them.”
“I think it is an excellent study and the results are accurate,” said Dr. Vert Mooney, chairman of the orthopedic surgery division of the University of Texas in Dallas. “I think the pendulum is beginning to swing against bed rest and there is every scientific reason to believe that prolonged bed rest is actually dis abling. It causes (muscle) atrophy and a loss of control and a weakening of body tissues.”
He said tall people may be rendered prone to back pain not just by the size of their skeletons but by the toll taken on their spines by repeated rapid slowing of motor vehicles in which they are riding that may put unusual loads on their longer-than-average backs and predispose them to back injury under other circumstances.
A patient who has what becomes chronic, minor back pain often also can be reassured that there is nothing inherently wrong with with him or her and continue with life, work and recreation tolerating a small amount of pain.
“Many patients would accept (this) in order to get on with their lives, as long as they were doing themselves no harm,” wrote Dr. Nortin Hadler, of the University of North Carolina School of Medicine, in an editorial published with Deyo’s study.
“It is a message that has not been heard in a long time, and it is refreshing.”
- Researchers say 60% to 80% of Americans experience low back pain between the ages of 25 and 69.
- By some estimates, 50% to 70% of back pain is precipitated by psychological forces.
- An object held at arms length puts 15 times more pressure on the spine than one held against the body.
- Two days of bed rest may help a bad back more than two weeks in bed, one expert says.
