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
abnormalitiesand most are pain-free.
New research suggests that emotional factorsespecially
stressmay 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 realand 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.
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
corda 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
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
Complications of osteoporosis
Once osteoporosis has developed, commonplace activitiesraising
a window, picking up a bag of groceries, even a bumpy car ridecan
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
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 painprovided 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 recuperationthe
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 peopleincluding celebrities like radio personality
Howard Stern and consumer reporter John Stosselsay
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:
Chronic Pain Association
From The Johns
Hopkins Medical Letter: Health After 50, March 2000.