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Back Pain & Osteoporosis

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The Right Prescription for Easing Back Pain

Each day, 6.5 million Americans are plagued by persistent back pain, one of the most difficult medical problems to diagnose and treat. Each year, back problems temporarily disable 17% of the U.S. work force and cost billions of dollars in lost wages. Symptoms are usually blamed on slippage, rupture, or degeneration of the spongy protective discs located between each vertebra. But studies show that more than half of all adults have these abnormalities—and most are pain-free.

New research suggests that emotional factors—especially stress—may also contribute to back pain. When researchers at several institutions, including the Johns Hopkins University School of Public Health, studied 200 injured municipal workers for 13 months, they found a significant association between low back pain and job stress. The findings, reported in the American Journal of Public Health, showed that highly stressed workers were 2.1 times more likely to develop a back injury than those with low stress; the rate for moderately stressed workers was 1.7 times higher.

Despite the possibility that the underlying cause of some back pain may be psychosomatic, sufferers are not "crazy." Their pain is real—and it should be addressed. In 1994, a government panel concluded that a day or two of rest followed by the gradual resumption of daily activities is generally the best treatment. Other therapies include pain killers and muscle relaxants; cold and heat treatments; massage, stretching, and back-strengthening exercises; acupuncture; and surgery. For those with persistent pain despite treatment, support groups may be helpful (see sidebar).

But relying on these approaches may not be appropriate for older adults because aging increases the risk of certain degenerative conditions that frequently affect the spine. If proper treatment of these spinal complications is delayed, back pain may persist and the spine may deteriorate beyond repair.

Spinal changes

The spinal column is formed by a series of 26 bones called vertebrae. The vertebrae are stacked on top of one another and create a channel called the spinal canal. With a diameter of about an inch, the spinal canal is the conduit for the spinal cord—a bundle of nerves that connect the brain with the rest of the body via the peripheral nervous system. The vertebrae are supported by muscles and connective tissue and protected by cartilage (strong, elastic tissue within the joints). The discs between each vertebra provide cushioning and additional protection.

Merely getting older increases the risk of osteoarthritis (erosion of joint cartilage) and osteoporosis (weak bones that break easily). Osteoarthritis can be caused by injury or normal wear and tear. It affects virtually all older adults to some extent. Osteoporosis is caused by accelerated loss of calcium, the major mineral component of bone. It affects about half of all postmenopausal women and up to one third of men over age 70. Both conditions can affect the spine.

Complications of osteoarthritis

As osteoarthritis erodes vertebral cartilage, the vertebrae frequently begin to scrape against one another, triggering irritation, inflammation, and tiny, abnormal outgrowths of bone called spurs (osteophytes). These changes can narrow the spinal canal, a phenomenon known as spinal stenosis.

People with spinal stenosis often have episodes of back pain followed by periods of relative comfort. Other symptoms include pain in one or both legs, particularly when the spine is straight. Some sufferers complain that their legs feel rubbery, numb, or weak. Pain usually worsens when walking down hills or stairs and eases when bending over or sitting. In rare cases, sciatic pain (shooting pain from the lower back down the leg due to pressure on a sciatic nerve) may develop. Occasionally, severe cases affect the nerves to the bladder and bowel.

Fortunately, because osteoarthritis develops gradually, symptoms usually remain relatively mild and often improve with time. Flare-ups usually subside after a day or two of rest, followed by a gradual increase in physical activity. Pain-relieving medication, along with heat or cold applications, may also be helpful. Some sufferers wear a brace to protect and stabilize the back. Long-term treatment involves back strengthening exercises, stretching, and low-impact aerobic activities (especially walking and swimming). If symptoms are severe and continue to interfere with daily activities despite these measures, a surgical procedure called laminectomy may be considered.

Laminectomy relieves pressure on the spinal cord by removing fragments of bone and other tissue responsible for narrowing. If an extensive amount of tissue is eliminated, it may be necessary to stabilize the spinal column by fusing together two or more vertebrae. Fusion may cause a slight decrease in flexibility. Laminectomy requires a 4- to 7-day hospital stay. Results are usually excellent if stenosis is limited to one or two vertebrae and tend to be better in patients with leg pain only.

Complications of osteoporosis

Once osteoporosis has developed, commonplace activities—raising a window, picking up a bag of groceries, even a bumpy car ride—can trigger tiny fractures in the vertebrae. About 70% of sufferers experience severe pain for three weeks afterward, but debilitating pain may linger for three months. A fracture in the lower back may prompt urinary difficulty for a few days because of swelling near the nerves that communicate with the bladder muscles. About 40% of women with osteoporosis (and a small number of men with the condition) experience multiple fractures, either simultaneously or over many years. These fractures frequently lead to kyphosis (dowager's hump), a condition characterized by stooped posture and a 15 to 20% reduction in height.

Although stooped posture cannot be reversed or lost height restored, spinal fractures mend. Treatment is designed to support this process. One to two weeks of bed rest is mandatory. Because it's often impossible to get comfortable lying flat, a recliner, lounge chair, or hospital bed may be better than a conventional bed. Ice packs applied to the affected area for up to 10 minutes once every hour may be soothing, and pain relievers can be taken as needed. Once healing is under way, moist heat (a hot bath, hot-water bottle, heat pack, or damp towel wrapped around a waterproof heating pad) for up to 20 minutes every few hours may be more effective. Sometimes a lightweight brace can help relieve back fatigue, increase mobility, and prevent movements that trigger pain.

Extremely painful or severely debilitating spinal fractures can also be treated with vertebroplasty, an outpatient procedure recently imported from Europe. Using guided imaging, a physician specializing in interventional radiology inserts a needle into the injured vertebra and injects bone cement, a material that is also used for hip fractures. The cement dries within about 15 minutes, reinforcing the spine, providing stability, and preventing further deterioration and friction. The hour-long procedure is followed by three hours of observation. Up to three fractures can be treated at a time. Most patients experience an immediate, marked reduction in pain, and about 80% are pain free within a few days. The most serious complication, though rare in the hands of an experienced doctor, is improper positioning of cement, which can lead to permanent paralysis. Vertebroplasty is currently available at a limited number of centers. For more information, call the Johns Hopkins Interventional Neuroradiology Service (410-955-8525).

People with osteoporosis require therapy, often for life, with bone-preserving medications. These include hormone replacement therapy and raloxifene (for women only), alendronate (Fosamax), and calcitonin. Exercises to strengthen the back and keep it flexible are also important. But the program must be tailored to each patient's limitations, and care must be taken to protect the spine. Chiropractic manipulation is not recommended, however, because of the possibility of injury.

 

The Value of Support Groups

"A support group is worth a try for people suffering from chronic back pain—provided they have been thoroughly evaluated for structural problems that may require specific treatments," says Health After 50 board member and psychiatrist Dr. Peter Rabins. Such groups offer participants an opportunity to share experiences and learn coping skills. Many include an educational component that provides information about back anatomy and physiology, proper lifting techniques, and safe exercise strategies. They also help reduce a major obstacle to recuperation—the fear that activity will lead to more pain.

One recently publicized approach, developed by Dr. John Sarno, a professor of clinical rehabilitation medicine at New York University School of Medicine and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine, proposes a connection between back pain and repressed anger. According to Dr. Sarno, the anger causes the brain to reduce the blood supply to back tissues, resulting in pain. Treatment is based on education. Patients attend a series of sessions that focus on the anger hypothesis. Though the mechanisms by which anger may cause back pain are unknown and highly speculative, many people—including celebrities like radio personality Howard Stern and consumer reporter John Stossel—say they've been helped by Dr. Sarno's techniques.

"While such an approach may help, it's unlikely that any one psychological issue is relevant to all individuals with back pain or any other medical problem," Dr. Rabins says. Our recommendation: Look for a program offered by a multidisciplinary pain center or clinic that offers a variety of diagnostic and treatment services. Such facilities are sometimes accredited by the Commission on Accreditation of Rehabilitation Facilities (520-325-1044). While not required, accreditation offers some measure of assurance that the program is comprehensive


For more information:
Arthritis Foundation
Atlanta, GA
800-283-7800
National Osteoporosis Foundation
Washington, D.C.
202-223-2226
American Chronic Pain Association
Rocklin, CA
916-632-0922
American Pain Society
Glenview, IL
847-375-4715

 

From The Johns Hopkins Medical Letter: Health After 50, March 2000.

 


 


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2005
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Back Pain & Osteoporosis

The Back Pain and Osteoporosis White Paper from The Johns Hopkins White Papers series is an annual, in-depth report written by Hopkins physicians.


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Johns Hopkins Medical Letter: Health After 50
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