Back Trouble: The Painful Paradox

Walking into the exam room, one was immediately struck by his suffering. He was neither sitting nor standing but “perched” on the end of the examining table, using his arms as crutches to support the weight of his upper body.

The examination gown he had been given to wear sat neatly folded next to him, and he remained dressed. His navy blue shirt was dark in spots with perspiration, and beads of sweat were visible on his forehead. Too uncomfortable to talk much, he asked his wife to retell his story--a tale of low-back pain that began after he slipped and fell.

The physical examination suggested a severely strained back muscle, and he was sent home with a prescription for anti-inflammatory medication and another for pain relief, a recommendation to rest and reassurance. But neither he nor his wife looked reassured. Again, she spoke for both: “Given the amount of pain he is in, shouldn’t more be done?”

This case illustrates the paradox of acute low-back pain: The severity of the pain may bear little or no relationship to its underlying cause or to the intensity of the therapy required. In fact, most acute back pain is caused by simple strain or sprain of under-conditioned and overstressed back muscles and ligaments. Such problems will usually resolve themselves without any treatment in less than a month.

Another relatively common cause of back pain is herniation of the intervertebral disc, commonly called a “slipped” disc. This occurs when the soft “pads” between the vertebral bones in the spine are injured or begin to degenerate and lose their shape. A damaged, misshapen disc can compress nerves as they leave the spinal cord, which may result in pain, numbness, tingling or weakness that extends into the buttocks and legs.

Like the pain of strains and sprains, the discomfort of a slipped disc almost always improves with relatively simple interventions. Ibuprofen and other nonsteroidal anti-inflammatory drugs, or NSAIDS, are frequently prescribed to reduce inflammation in the involved disc and surrounding tissues and to control pain. Muscle relaxants also may be used to relieve the associated muscle spasm and alleviate symptoms. Two or three days of bed rest may also help curb inflammation.

It’s important, however, to return to normal physical activities as soon as possible, as longer periods of inactivity can actually weaken muscles and bones and delay recovery. Spinal manipulation by a well-trained and licensed practitioner can sometimes be helpful in the first several weeks. (Its usefulness beyond this point, however, is less clear).

Diagnostic tests, including X-rays, CAT scans and MRIs, are not usually necessary to properly diagnose and treat acute back pain. Even if the test did reveal a herniated disc, initial treatment would be the same. Despite this, many patients insist on having such tests, and some physicians routinely order them.

When acute back pain fails to improve within four weeks, it’s time to consider appropriate tests. Testing is also indicated if the patient’s history and physical exam suggest the possibility of a more serious underlying problem, such as an infection, fracture or tumor of the spine. In such cases, other warning signs, such as fever or a history of severe trauma, may indicate the need for an early extensive medical work-up.

Since back pain commonly recurs, prevention is the best medicine. A regular program of exercises designed to stretch and strengthen the back and abdominal muscles is one of the best preventive therapies. Exercises recommended by the American Academy of Orthopedics can be found on the group’s Web site at: https://www.orthoinfo.aaos.org.

Be aware that many back problems actually begin with overzealous workouts, so always begin your back conditioning program with light exercise and gradually increase the intensity. Regular aerobic exercise, such as walking or swimming, also appears to be useful.

Learning--and using--proper lifting techniques is also important to prevent recurrences. Never bend from the waist to lift any objects, even light ones. Instead, bend your knees to get down to the level of the object; then lift by straightening your legs, keeping your back straight at all times.

Sitting in the same position for extended periods can also set you up for an episode of acute back pain. If you must sit for long periods of time, use a chair with proper back support and get up and move around frequently. While seated, reduce the strain on your back by keeping one knee higher than the level of your hips. Try propping up one foot on a low stool or footrest, and then alternating the foot you keep elevated.

When driving a long distance or traveling by plane, make sure you get a chance to stand up and walk for a few minutes every couple of hours--or more frequently if your back begins to bother you.

Surgery for back pain once was common but now is the exception. That’s because less aggressive treatments are much safer and usually just as successful for most causes of low back pain. If back surgery is recommended, it is a good idea to get a second physician’s opinion.

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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. They can be reached at ourhealth@dhs.co.la.ca.us. Our Health runs the second and fourth Mondays of each month.