Oh, My Aching Back: Its in Your Head

It's in Your Head

Back pain affects nearly half of all adults in any given year and at least two-thirds at some point in their lives. It's so prevalent that in the United States, back pain is second only to upper respiratory infections as the reason people visit their doctors.

Unfortunately, many doctors don't have a clue about what causes back pain, so they order tests, which lead to unnecessary surgery for many people. But back pain usually doesn't signal a serious illness or condition, and in most cases, the pain will eventually go away with minimal treatment. Next time you feel the twinge of backache, here's what you need to know and do.

Why It Hurts
The mystery of back pain starts in your head, says Dennis C. Turk, Ph.D., a pain researcher at the University of Washington in Seattle. "Pain doesn't originate in the body but in the brain," he explains. "Let's say you strain your back. That information is transferred along nerve pathways to your brain, where it's interpreted as pain." And each person perceives that pain differently.

Brain chemistry seems to play a role in pain perception. Recent research at Upstate Medical University in Syracuse, N.Y., found that chronic back pain triggered changes in several brain chemicals, most notably one involved in brain cell communication. According to principal investigator Igor D. Grachev, M.D., Ph.D., a neuroscientist, a reduction in this chemical resulted in increased feelings of pain. "This could explain why someone may feel intense pain when an MRI of the spine shows only a minor problem," he says.

Low back pain can have many causes. It could be a pulled or strained muscle or ligament. It might be a herniated disk, which happens when tears in the outer part of a spinal disk release the jellylike substance that cushions the vertebra above and the one below. The cause might also be arthritis, osteoporosis, an infection of the spine, or physical trauma from a car accident or serious fall. Still another possibility is spinal stenosis, a condition in which bony overgrowths of the vertebrae narrow the spinal canal and hit nerve roots, notes Andrew J. Haig, M.D., director of the Spine Program at the University of Michigan in Ann Arbor. This condition is particularly common in people over 60.

If you have pain, sometimes accompanied by numbness or tingling that radiates down the back of your leg and below the knee, the problem may be sciatica. "Sciatica is usually caused by a herniated disk pressing on nerve roots," Haig says, "but occasionally, it's the result of spinal stenosis."

Although the potential causes are many, about 85 percent of the time no reason for the pain is ever found, Haig says. At best, diagnosis is often a guessing game. Some tantalizing new research, however, points to a genetic component in a small percentage of cases.

To try to figure out what's going on, doctors may order X-rays, MRIs, or CT scans. But all too frequently these tests either don't pinpoint the cause of the pain or they find other back conditions that aren't related to the pain.

"Studies have shown that an MRI or CT scan will show some 'problem' such as a herniated disk or spinal stenosis in one out of three people with absolutely no symptoms of back pain," Turk says. And when a test does show a spinal abnormality in someone with back pain, there's no guarantee that it's the cause of the pain.

Too Many Tests
"There's a tremendous problem with over-testing in this country," says John D. Loeser, M.D., a neurosurgeon at the University of Washington. Unfortunately, that over-testing may lead to unnecessary surgery. This is especially true for older people because of a misperception of what's "normal."

"Radiologists tend to believe that 'normal' equals a picture of an 18-year-old's spine," he points out. "They label age-related changes that occur in almost everyone over 65 as 'abnormal.'"

Does that mean testing is never called for? Of course not. Getting a picture of the spine is necessary for diagnosing low back pain in a person who has a history of cancer, a fever (which could indicate a spinal infection), or has undergone severe physical trauma. For others with low back pain, testing may be advisable if the pain fails to improve after four to six weeks of conservative treatment.

Saying No to the Knife
Surgeons perform approximately half a million back operations in the United States each year. Yet some experts suggest that an astonishing 95 to 98 percent of people with back pain do not require surgery.

When is surgery appropriate? If people have failed to get better after a reasonable period of time or if they have sciatica, they should consider an operation, Loeser says. "But even in these instances, surgery may not be the best choice," he adds. "If you leave disk disease alone, most people will get better with nothing more than physical therapy and other conservative treatment. The problem is that if there's a lot of pain, some people simply can't or won't endure it. A surgical procedure can reduce the pain quickly."

Wait and Watch

Nonsurgical Alternatives
About one out of three people with back pain will improve substantially in a week, and two out of three will feel better after seven weeks. So a wait-and-watch approach plus some simple pain-management strategies are the best course for most people, Haig says.

But that doesn't mean taking to your bed, he adds. In spite of the once-prevailing belief that bed rest is the best therapy for an aching back, doctors now advise just the opposite. "When people are confined to bed, they lose muscle mass, coordination, and balance," Haig says. "For every week you spend in bed, you need six to eight weeks to regain lost muscle and get yourself back in shape." If you feel you must rest, don't stay in bed for more than a couple of days and even then try to get up periodically and move around.

To reduce inflammation and pain, apply an ice pack for 20 to 30 minutes several times a day for the first day or two. After that, a heating pad set on low may offer some relief. Over-the-counter pain relievers such as acetaminophen, aspirin, or ibuprofen can also help.

If you don't feel any improvement after a month, see your doctor or seek help from a center that specializes in treating back pain. These programs combine the techniques of several specialists. In many of them, a physiatrist (a physician who specializes in rehabilitation Medicine) or other expert, such as an osteopath (whose training emphasizes musculoskeletal disorders), works with a physical therapist to develop an exercise regime that will stretch and strengthen the muscles and ligaments of the back and other parts of the body.

In some cases doctors recommend antidepressants, even if the person isn't depressed. "Antidepressants seem to regulate the brain's neurotransmitters that control sensory perceptions," Haig explains.

Anti-seizure medications may also relieve pain. "We don't know exactly why," Haig continues, "but when back pain becomes chronic, it cycles like a reverberating circuit in your brain, sending signals that say, 'I hurt, I hurt.' An anti-seizure drug may interrupt that cycle."

But, he cautions, these and other drugs have side effects. "People need to understand that they have a choice to use or not use medicine for pain," he says. "No Medicine cures all back pain. You and your doctor have to make a judgment based on the cost and side effects of a drug versus the amount of pain you're in."

If you have pain, especially from sciatica, that's so severe it keeps you from exercising, you may benefit from an epidural cortisone injection, Haig says. "These have been used for 15 or 20 years to reduce the inflammation and swelling around nerve roots, but until recently, doctors weren't able to inject the cortisone in exactly the right place. Today, however, some doctors use fluoroscopes to locate the site of the inflammation, so the injections are more accurate." Although no research shows that these epidural cortisone injections cure back pain, and relief lasts only two or three months, that may be enough time to begin an exercise program and start benefiting from it.

What Doesn't Work
Some common treatments for back pain either don't work at all or provide minimal relief at best. Traction, for example, has been shown to be ineffective. And a recent large-scale study found that back braces and support belts (items often sold through mail-order health products catalogs and magazine ads) not only do not relieve pain or prevent injury but may actually increase the risk of damage. These devices tend to give their wearers a false sense of security, making them more likely to move incorrectly and put undue strain on their backs.

Transcutaneous electrical nerve stimulation (TENS), a mild application of electrical current to the skin over the painful area, which attempts to block pain signals traveling to the brain, has also proved ineffective. On the other hand, a related procedure, percutaneous electrical nerve stimulation (PENS), in which acupuncture needles are used to deliver electricity, may offer some relief, according to preliminary research. Traditional acupuncture may relieve pain over the short term, but there's no evidence that the improvement lasts, according to Haig. The same goes for massage therapy. "We need careful research on both procedures," he says. "So far, the jury's still out."

As for magnet therapy? "It's a complete scam," Loeser says. "Don't waste your money."

Preventing Pain
To reduce your risk of developing back pain or to prevent a recurrence, "Stay strong, flexible, and coordinated," Haig says. That means committing yourself to a program of stretching, Aerobics, and strength training.

Also, if you still smoke, quit. "Research shows that cigarette smoking is a significant risk factor for back pain," Haig notes.

The way you sit or the mattress you sleep on may play some role in back pain, but not for reasons you might imagine. "There's no 'right' way to sit," Haig says. "What's important is that you are able to move around in your chair, to flex your back, and stretch your legs." An ideal chair has arms, provides support for your back (a lumbar cushion can be useful), and isn't so high that your legs dangle.

While folklore holds that a hard mattress is better for a bad back, you can sleep on whatever kind of mattress feels best, Haig says. It's a matter of individual choice. One may like to sleep on their side with a pillow between her knees or on her back with a pillow under her knees. Pillows work for some but not for others.

Ultimately, preventing back pain means staying active and exercising. And if you suffer from back pain, don't look to the experts for a quick fix. "Over the years, we've found that one of the major problems is that people with back pain have been misled into thinking that they can get rid of their symptoms if they find a smarter, better doctor," Loeser says. "But the truth is that they need to make themselves better."