You don't know how or where it began. Perhaps you simply sat too long. Or you bent over too quickly or stretched too far. But now the pain of a bad back has taken over your whole life.
Like a security alarm that can't be shut off, the discomfort of an ailing back can be merely annoying, but all too often it is blinding and debilitating in its intensity. And it can happen to anyone at any time.
Back ailments are among the most frequent health problems, second only to the common cold. Four of five adult Americans suffer from back pain sometime in their lives. About 1% of the population--2.5 million individuals--are totally and permanently disabled by chronic back problems. And the incidence of back pain, what the National Institutes of Health recently called "a crippling ailment of staggering dimensions," appears to be increasing faster than any other form of bodily injury.
As alarming as the frequency of back complaints is the mystery that surrounds them. Despite an arsenal of new tools, only about 17% of cases can be accurately and fully diagnosed, according to recent epidemiological studies.
Yet there is good news for many of the 8 million Americans who will be stricken with back pain this year and the nearly 80 million already afflicted. Thanks to new insights into the mechanics and biochemistry of the spine and radical rethinking about how to treat back pain, the majority of back problems can be brought under control and in some cases--with the right diet, proper exercises and new work and leisure habits--can be prevented.
"There is no cure for back pain," cautions Michael Schlink, founder of Schlink & Associates, a physical-therapy group in West Los Angeles that specializes in back pain and other orthopedic ailments. There is, he says, "control and prevention. More than almost any other area of medicine, it is up to the patient to do the controlling and the preventing."
Back-pain sufferers, Schlink says, cannot passively submit to doctors or therapists and hope to find a permanent remedy for their back problems. Nor can they rely on often-prescribed pills--anti-inflammatory drugs and pain relievers--to offer anything more than temporary relief.
"This is one area of medicine," he says, "where a patient cannot be a patient."
What that means to the sufferer is exercise to strengthen all parts of the body: stretching leg, neck and pelvis muscles and learning to stabilize and control the trunk of the body so that the spine always remains in its natural alignment, says Dr. Lionel A. Walpin, former director of physical medicine at Cedars-Sinai Medical Center and now medical director of the Walpin Physical Medicine and Pain Institute in Los Angeles.
Which exercise works best will vary from person to person, depending on body condition and the precise nature of the ailment, Walpin says. But virtually every back patient will benefit from routine stretching and strengthening exercises, along with regular aerobic activity, either swimming or vigorous walking for at least 20 minutes a day.
That assessment, shared by most health-care professionals, is based on long-term epidemiological studies of back patients and recent research on the mechanics of the spine and the biochemistry of discs and other soft tissues that support the back.
Current thinking about what works--and what doesn't--would have been considered medical heresy a decade ago, says Dr. August A. White III, an orthopedic surgeon at Harvard Medical School.
Posture, for example, is now believed to be neither a cause of back pain nor a cure for it. Evidence that the admonition to "stand up straight" does little, if anything, to keep people from having back pain comes in part from a detailed review of "posture pictures" taken as part of fitness programs in women's colleges in the 1950s.
"Posture . . . good nor bad, was not in any way associated with a higher or lower incidence of low-back pain over a 25-year period," White notes in his 1990 book on back pain.
Heat and massage, two of the oldest and most trusted remedies, are now considered by most physicians and physical therapists to offer little more than temporary, palliative relief.
The same is true of bed rest. According to experts, taking to bed for more than a few days during an acute bout of back pain might do more harm than good, causing the muscles that are needed in recovery to atrophy and exacerbating the feelings of helplessness and depression that often accompany back pain.
Back surgery, once considered to be the riskiest but only permanent remedy for back ailments, also has fallen out of favor--even with prominent back surgeons. "Surgery should be the last treatment a patient considers. And even then, the patient should get a second opinion," says Dr. Theodore B. Goldstein, a Beverly Hills orthopedic surgeon who specializes in back surgery.
That's not to say spinal surgery is as "fearsome" a proposition as it once was, notes Goldstein, a founding member of the Spine Institute, which will be Los Angeles' first private center for the treatment and diagnosis of back problems when it opens this spring.
With the right patient and the right diagnosis, the success rate for surgery on a herniated disc, the most common back operation, now runs as high as 94%, thanks to new diagnostic techniques that have made exploratory back surgery unnecessary, and new operating techniques employing fiber-optic lighting and microscopic instruments, which result in smaller incisions and faster recoveries.
Recovering from back surgery, however, is much like avoiding surgery in the first place, Goldstein says. It requires physical activity and fundamental changes in the patient's lifestyle. That means changing the way a back patient moves.
All evidence indicates that many back problems are the result of "movement disorders," chronic, repetitive movements that put undue stress and strain on the spine and surrounding tissue, says Rob Landell, a USC professor of physical therapy.
"The right kind of exercise, done properly and regularly, can prevent many of these problems from happening," Landell says.
Exercise not only can strengthen and stretch muscles, giving the spine the support and agility it needs, but it also can relieve stress, now thought to be one of the precipitating causes of painful muscle spasm. Exercise might even relieve pain by causing the body to release its own natural painkilling chemicals.
The problem is finding the right exercise for a patient.
Back pain is not always a matter of a single defect that can be corrected by a simple procedure or a standard set of exercises, says Dr. William H. Dillon, an orthopedic surgeon at the Kerlan-Jobe Orthopedic Clinic in Inglewood.
Often, something goes wrong in one area, and the patient uses another to compensate for it. A muscle strain can aggravate a disc tear. A disc tear can cause a muscle strain. A joint problem might trigger a muscle problem. While the patient might feel pain in one place, the pain might be relayed down nerve pathways from somewhere else.
Just as finding the right exercise is something of an inexact science, so is predicting who is susceptible to back problems. At high risk for back injury are not only those who lead sedentary lives but also those who are extremely active. Nurses who lift patients and postal workers who carry heavy packages are at high risk for back problems, as are lawyers, secretaries and writers who sit at desks all day.
Epidemiological studies have found that Americans who spend at least half their work hours in an automobile are three times more likely than average workers to have back pain. Traveling salesmen and delivery people are often at risk.
Obesity and pregnancy appear to put people at risk. Just as picking up a heavy package can throw a back out of alignment and cause excruciating pain, so can a protruding stomach force the body's center of gravity forward. High-heeled shoes (more than one inch high) seem to have a similar effect, throwing the body off balance enough to put unnecessary and potentially hazardous strain on the spine.
Even smoking has been implicated. A chronic cough has long been thought to place inordinate stress on the muscles and ligaments surrounding the spine. Scientists also believe that nicotine might cause biochemical damage to discs, which are jellyroll-like tissues that lie between the vertebrae and function essentially as the spine's shock absorbers. By restricting the flow of blood to the spine, scientists theorize, nicotine cuts off needed oxygen to body tissues, essentially speeding up the aging process and causing discs to crack and dry up.
The onset of back problems, according to surveys by the National Institutes of Health, tends to occur between the ages of 30 and 55. While the risk of back pain decreases for men after 50, it rises for women largely, researchers think, because elderly women are prone to osteoporosis, a loss of bone density that can weaken the vertebrae.
Cultural and racial differences might play a role. According to some epidemiological studies, American whites are more prone to disease than are blacks, and Eskimos are 10 times more prone to certain back ailments than are Caucasians.
While certain individuals might be predisposed to back problems by an inherited weakness or a malformation of the spine, the majority of back sufferers "have brought on the problems themselves," Landell says.
Sitting eight hours a day in a poorly designed chair, riding for hours in a soft seat of a vibrating car, cradling a telephone receiver in the crook of the neck, even sleeping on the wrong kind of mattress can cause permanent back problems. "Eighty million people (in the United States) have back problems," Landell says. "But there aren't 80 million people born with defects. It's how we live. Backs are like credit cards. You bend them and bend them the same way again and again, and eventually they snap."
In fact, backs do not actually snap even with prolonged abuse. What is thought to happen in most cases--probably about 90% of all backaches--is that something, an accident, perhaps, or a sudden twist of a poorly conditioned body, causes a muscle strain in the lower back.
Because lower backs receive the brunt of the stress on the body--bending, stooping, sitting, lifting--the majority of problems are located in or around what is known as the lumbar region of the spine, between the L1 and the L5 vertebrae, above the pelvis and below the chest. A much smaller percentage of problems occur in the neck, or cervical region of the spine, between the C1 and the C7 vertebrae, which supports the weight of the head. Only the middle back, the thoracic region of the spine, between the T1 and T12 vertebrae, is relatively free from ordinary stress.
Wherever they occur, two-thirds of all back problems will resolve themselves within 30 days, and at least 90% will disappear within six to 12 weeks of the onset of symptoms, no matter where they occur or what the treatment, researchers have observed. The problem, according to experts, is there is often no way of knowing initially if the symptoms are signs of more serious damage or whether they will recur.
Doctors cite a number of specific problems that might be cause for concern and that should receive immediate medical attention. Pain is not necessarily one of them. Even excruciating pain, if short-lived, is not always a sign of a serious problem. Numbness and tingling in toes and fingers can be. So can loss of movement or strength in any part of the body. Perhaps the most common reason to seek medical health is sciatica, an often excruciatingly painful sensation down the legs, which affects as much as 40% of the adult population at some point in their lives.
Although these and other symptoms might be temporary, they also might be signs of serious disorders: a herniated or bulging disc that is impinging on nerves radiating from the spinal cord; various forms of spinal arthritis, inflammatory diseases that can cause pain and crippling; scoliosis or curvature of the spine, a defect that often occurs in childhood and, if not treated, can result in severe deformities; tumors, either benign or malignant growths, which, although rare, can impinge on the central nervous system, causing pain and, in some cases, paralysis.
Partial diagnosis of back problems can be made by way of a physical exam, along with X-rays of the spine, which show defects in the bone, and CAT scans and Magnetic Resonance Images, two imaging techniques that can reveal damage to muscles, ligaments, discs and other soft tissues.
Fifteen years ago when the latter of these diagnostic tools were introduced, it was thought that they would provide definitive explanations for the causes of back ailments. Recent studies have shown, however, that they, too, often provide an incomplete and often inaccurate picture. In about a third of all cases, the pictures reveal spinal problems in people who don't have back pain. And they seldom tell the whole story of why people do have back pain.
Sorting through this maze can be tricky, and most back sufferers would do well to seek professional advice. But who can give the best advice?
Just as there's no one cause of back pain, so there's no one specialist who is right for every patient. Neurologists and neurosurgeons specialize in nerve disorders and spinal injuries. Orthopedists and orthopedic surgeons treat diseases and injuries involving bones, muscles, ligaments, tendons and joints. Physiatrists, also known as physical-medicine doctors, specialize in the rehabilitation of the muscular-skeletal system. Osteopathic physicians focus on the links between organs and the muscular-skeletal system.
There are many allied-health professionals who treat back disorders. Acupuncturists, trained in an ancient Chinese art, place wire-thin needles in the skin to relieve pain. Physical therapists, licensed practitioners widely used by orthopedists and neurosurgeons, evaluate back problems and design long-term treatment plans, relying heavily on exercise programs that improve both the spine's strength and its flexibility.
Perhaps the most controversial specialist is the chiropractor. While many people swear by them, surgeons and physicians have long been skeptical about the efficacy and even the safety of spinal manipulation, especially for patients with major structural abnormalities.
While agreeing that not every back sufferer can safely benefit from manipulation of the spine, a recent and important study in the British Medical Journal concluded that, for some patients, chiropractic treatment was more effective and lasted longer than regular medical treatment. For reasons that are not entirely clear, the study found, those who benefited most were patients who had severe pain or had had more than one bout of back pain. Chiropractic treatment appeared to have the least advantage for patients who had had no prior episode of back pain.
A relatively new approach to treating backs is the "back school."
Modeled after rehabilitation and prevention programs in Volvo factories in Sweden, these group classes are usually taught by university and hospital physical therapists and are designed to educate patients about the causes of movement disorders and to train back patients in proper exercise techniques.
One of the advantages of a group class, as compared to individual treatment, is that patients learn tricks from each other. As one UCLA back-class student patient put it: "If you've got a bad back, you've got to relearn almost everything you do--how to fold laundry, how to get in and out of a car, even how to sit and watch TV without wrenching your back out of shape."
"Most people with back problems do almost everything wrong," says USC's Landell. "They bend over incorrectly. They sit for hours in front of the TV with their heads cocked at a slightly odd angle. Years of that, day in and day out, night in and night out, and they've got a problem.
"The ones who will get better are the ones who take an active role in bringing about permanent changes in their lives. The ones who say to the doctor or the physical therapist, 'Here's my back; I'm going shopping; I'll be back in an hour' are not the ones who are going to get better."
Unfortunately, even patients who initially are willing to make changes and adhere to rigorous exercise routines often don't want to keep them up indefinitely, Landell says. "A lot of patients worry, 'Am I going to have to do all these things for the rest of my life?' To that I simply say, 'If your eyes are failing, you'll wear glasses for the rest of your life, won't you?' "