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The American Academy of Family Physicians, founded in 1947, is one of the largest national medical organizations, with more than 94,000 members in the U.S. and its territories. Until 1971, it was known as the American Academy of General Practice. The name was changed to reflect more accurately the changing nature of primary health care. The Academy promotes and maintains high quality standards for family doctors who are providing continuing comprehensive health care to the public.
The American Academy of Orthopaedic Surgeons (AAOS) provides education and practice management services for orthopaedic surgeons and allied health professionals. The Academy also serves as an advocate for improved patient care, and informs the public about the science of orthopaedics. Founded at Northwestern University as a not-for-profit organization in 1933, the Academy has grown from a small organization serving fewer than 500 members to the world's largest medical association of musculoskeletal specialists. The Academy now serves about 24,000 members internationally.
The National Library of Medicine (NLM), on the campus of the National Institutes of Health in Bethesda, Md., is the world's largest medical library. Its collections stand at more than 7 million items. NLM is a national resource for all U.S. health science libraries through a National Network of Libraries of Medicine. Information is available in the database MEDLINE, the major component of PubMed, which is freely accessible via the web (http://www.nlm.nih.gov). NLM has created a special Web site, MedlinePlus, to link the general public to many sources of consumer health information.
Part of the National Institutes of Health, NINDS purpose is to reduce the burden of neurological disease, including back pain. Some of the research conducted by NINDS consists of testing different drug treatments for back pain, as well as investigating complimentary and alternative medicine therapies.
The FDA web site includes a description of "What to Do When Your Back Is in Pain", an article describing back pain, treatment options and helpful exercises to alleviate pain as well as ways to prevent back injury.
As part of their Handouts on Health, NIAMS developed this booklet on back pain: "This booklet is for people who have back pain, as well as family members, friends, and others who want to find out more about it". It contains extensive information on the causes, diagnosis, treatments, and research programs currently being pursued in order to improve the quality of life for people who suffer from back pain.
Episode number: 
210

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Transcript: 
Back Pain (transcript)

If you've never had reason to say, "Oh, my aching back!" count yourself among the fortunate few.  Fully seven out of every ten people will endure back pain at some time in their lives.  For most, the problem will clear up in a few weeks or less.  Nonetheless, back pain is one of the most common afflictions in our society, responsible for millions of lost work hours and millions in health care expenditures – not to mention its disruptive impact on one's day-to-day life.

In this episode of Second Opinion, a panel of orthopaedic experts and others familiar with the ailment come together to explore the symptoms, causes and treatments of back pain.  Along the way, they discuss such key issues as:

  • How much is known about the causes of back pain?
  • When is a visit to the doctor advisable, and when will self-care measures work?
  • Which treatments are effective and which are not?
  • What distinguishes typical back pain from more serious back problems?
  • Can low back pain be avoided?

A majority of people between the ages of 35 and 60 experience back pain, and most of those episodes affect the lumbar – or lower – back.  (The development of back pain in younger or older people might indicate a different, more serious problem.)  It is the most common reason people under 45 must limit their activity, and the second most common reason people visit the doctor (colds/flu is the first).  The ailment is termed "acute" when it is present fewer than 12 weeks, and "chronic" when it lingers for longer periods of time.

Up to 90 percent of cases can't be traced to a specific illness or pathology, but there are common risk factors. Sometimes back pain develops for no apparent reason at all.  In physical exams and x-rays, doctors may or may not find a specific change or condition in the back that correlates with the patient's symptoms.

The good news is that two out of three people who develop back pain recover within weeks.  Nine out of 10 are back to full activity within two months.  For some people with back pain, however, their lives are never the same.  Chances are, a patient who has been out of work for two years likely will never return to full-time status.  Many chronic sufferers simply learn to live with the pain.  They never achieve the mobility and ability to function normally that they once enjoyed.  Treatment moves from curing the condition to minimizing symptoms.

 

Quick Facts

  • Back pain is the second-most common reason that people visit their doctors (behind colds / flu).
  • The majority of episodes occur in the lumbar spine – or lower back – which is comprised of five vertebrae and the discs that act as shock absorbers between these bones.
  • Back pain can occur suddenly or come on slowly.  It can follow an obvious injury/strain or develop "out of the blue."
  • Pain sometimes travels from the back into the neck, arms, buttocks and legs.
  • The primary cause of back pain is strained muscle, ligaments or tendons around the spine.
  • For most people, back pain will clear up in a few weeks or less.
  • Some people with chronic back pain will never return to the workplace or to a normal quality of life.
  • First-time back pain in people under 35 or over 60 can indicate more serious medical problems.
  • A CT (computed tomography) scan reveals the soft structures of the spine as well as its bone structures, and therefore is sometimes a useful diagnostic tool.
  • A physical exam often will determine a person with back pain to be normal except for experiencing pain with motion.
  • There is no consensus among doctors about how non-injury-related back pain develops.
  • There is widespread agreement about how to treat back pain:  a combination of pain relievers, measured physical activity and constructive changes in behavior.
  • The most effective of all drugs used to treat back pain are non-steroidal anti-inflammatory drugs (NSAIDs).  There are a wide variety of prescription NSAIDS and over-the-counter NSAIDS like ibuprofen, naproxen sodium, and ketoprofen.
  • Doctors recommend that, if at all possible, sufferers should stay active and keep bed rest to a minimum.
  • There is little evidence that "alternative" treatments – such as acupuncture, biofeedback, electrical stimulation, magnets, massage, back braces, etc. – provide any help or relief.

*Quick Facts have been reviewed by Medical Advisors and are current as of October 2005.

Ask Your Doctor

This list of questions is a good starting point for discussion with your doctor. However, it is not a comprehensive list.

General questions about Back Pain

  • What are the most common causes of back pain?
  • What does the pain usually feel like?
  • Are there related symptoms?
  • Are certain people / body types predisposed to back problems?
  • Can people who are physically fit experience back pain?
  • Why do most episodes affect the lumbar, or lower, back?
  • Is it true that back problems can develop for no apparent reason?
  • What, if anything, can be done to avoid back pain?
  • Which behaviors might increase the risk of back pain?
  • What causes the occasional associated numbness or tingling in the limbs?
  • What are the most common treatments for back pain?
  • Should I always see a doctor when I experience back pain?
  • What is "self care" and what does it entail?

Questions you might ask your doctor

  • Which diagnostic techniques are most helpful in identifying the causes of back pain?
  • What types of medications are most helpful?
  • Do you apply ice or heat to a sore back?
  • How helpful is bed rest?  Traction?  Cortisone shots?  Acupuncture?
  • Can people with back pain engage in physical activity?
  • Why do doctors often prefer a combination of treatments?
  • What does it mean if back pain "travels" to other areas of the body?
  • When is back pain "typical" and when might it indicate a more serious problem?
  • Do the underlying conditions for short-term and long-term pain differ?
  • Is there an optimum position for standing?  Sitting?  Sleeping?
  • Why does back pain clear up sometimes and linger other times?
  • What is a herniated disc?
  • What is sciatica?

Questions your doctor might ask you

  • Is your pain on one side only or on both sides?
  • What does the pain feel like?  Is it dull, sharp, throbbing, burning?
  • Is this the first time you have had back pain?
  • If you have had back pain before, is this pain similar or different?
  • Do you know the cause of previous episodes of back pain?
  • When did the pain begin?
  • How did the pain start – suddenly or gradually?
  • What were you doing just before the pain began?
  • Did you have a particular injury or accident?
  • How long does each episode of back pain usually last?
  • Do you feel pain anywhere other than your back, like your hip, thigh, leg or feet?
  • Do you have any numbness or tingling?  Any weakness or loss of function in your leg or elsewhere?
  • What makes the pain worse?  Lifting, twisting, standing or sitting?
  • What makes you feel better?
  • Are there any other symptoms present, such as weight loss, fever, a change in urination or bowel habits?

Adapted from information available on the following web sites:

Key Point 1

Back pain is one of the most common physical complaints.  If the condition does not improve within two days, see a health care practitioner experienced in back conditions.

Most people experience at least one backache in their lives.  And most backaches occur in the lumbar region, or lower back – which supports most of the body's weight.  Low back pain can emanate from the spine, nearby bones, muscles, nerves – just about any related structure.  It can appear immediately or develop over a period of time.  The cause might be obvious – such as a strain or injury – or a total mystery.  The pain itself might be sharp, dull, throbbing, burning, tingling, localized, widespread, radiating, a mere nuisance or breath-takingly severe.  It can pass in days or weeks, or linger for months or years.  All of this falls under the clinical heading of back pain.

The most common causes of back pain are a strain (such as from lifting), an injury and sitting in one position for a long period.  The condition might be incubating for a long period before the pain strikes.  The specific change in the back might never be identified, but people are at particular risk from the following:

  • Work involving heavy lifting, bending, twisting or vibration
  • Bad posture
  • Pregnancy
  • Advancing age  (30 and above)
  • Smoking
  • Lack of exercise or physical activity
  • Obesity
  • Arthritis
  • Osteoporosis
  • Ongoing stress
  • Clinical depression

If pain persists to the point where a doctor's visit is required, the diagnostic process will attempt to rule out more serious underlying causes – nerve disorder, fracture, infection, tumor, etc.  The doctor will check for:

  • Long-term chronic pain
  • Numbness or tingling in the legs
  • Muscle weaknessPoor blood circulation
  • Redness or swelling on the back
  • Loss of bowel or bladder control
  • Recent accident or injury
  • Fever
  • Unusual age for a first-time episode  (under 30 and over 65)
  • Cancer or a family history of cancer
  • Steroid or intravenous drug use
  • Unintended weight loss

Interestingly, a physical exam often will determine a person with back pain to be normal – except for the pain.  X-rays are almost always unhelpful in finding an explanation for back pain, so they are often not taken at the first visit.  Even if the x-ray does pick up an abnormality, plenty of people have abnormalities in their backs and don't experience pain.  MRI (magnetic resonance imaging) or CT (computed tomography) scans provide "3-D" x-rays and reveal the soft structures of the spine – discs, tendons, etc. – as well as bone structures, and therefore are sometimes useful diagnostic tools.

Doctors commonly ask a host of questions to get at the patient's recent activities, living habits and current symptoms.  Because most episodes of back pain clear up in a few weeks or less, medical tests probably will not be ordered for the first visit.  However, the patient will be asked to stand, sit and walk, bend in various directions, perform leg lifts while lying down and similar exercises to pinpoint the source and severity of the pain.

    

Key Point 2

Of all the drug treatments available for simple back pain, over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) provide the best overall improvement.

While there is no consensus among doctors about how non-injury-related back pain develops, there is widespread agreement about how to treat back pain – a combination of pain relievers, measured physical activity, and constructive changes in behavior.  And in almost every case, the best drug treatment is also the simplest:  popular over-the-counter NSAIDs (non-steroidal anti-inflammatory drugs), such as Advil and Motrin, can be very effective – even when compared with many prescription drugs.

Through vast experience treating millions of back pain cases, doctors have determined that the anti-inflammatory properties of NSAIDs provide the best relief for common back pain.  On occasion acetaminophen-based drugs like Tylenol can be helpful.  In more severe cases, stronger medications – muscle relaxants and narcotic-based medications – are prescribed for short periods.  These decisions should only be made with your doctor.

Of course, in order to be fully effective, drug treatments should be part of a larger rehabilitative program that includes physical activity, lifestyle changes and other factors. 

    

Key Point 3

Even for serious cases, intensive treatment and good follow-up care can significantly reduce back pain, restore normal function and mobility, and help reduce recurrences.

Many cases of back pain subside after a few days, with enough improvement to allow the patient to resume normal activities.  Cases requiring attention are usually treated in the following manner – and usually at home as "self care":

  • Cessation of all normal and especially strenuous activities
  • Simple NSAIDs (non-steroidal anti-inflammatory drugs) for pain relief, such as aspirin, Advil, Alleve or Motrin
  • Ice for the first 24 to 28 hours after pain develops, then heat after that
  • No more than a day or two of bed rest, if possible, after the onset of pain
  • Easy-motion aerobic exercises – walking, riding a stationery bicycle, swimming – as soon as they can be performed without aggravating the condition
  • Sleep in the "fetal position" with a pillow between the knees, or facing up with a pillow under the knees

One popular misconception is that bed rest is beneficial.  But doctors have determined that, not only is remaining stationary not beneficial, it can be a cause of, or contribute to, back pain.  Current medical wisdom encourages movement and activity as soon as the patient's pain subsides enough to permit it.

The simple treatment regimen above should do the trick in most cases.  If pain persists, however, it might be time to visit a health care practitioner with a good knowledge of back pain.  The result could be any of the following treatments, all of which are proven to provide at least some relief:

  • Physical therapy
  • Stronger drug treatment
  • Spinal manipulation
  • Injections of cortisone or a local anesthetic

There are new treatments designed to remove or neutralize the structure in the back believed to be causing the pain.  They include intradiscal electrothermy (IDET) and radio frequency ablation (RFA).  These treatments entail some risk and have the potential for long-term side effects.  But they may be preferable in some instances, to a traditional surgery.

There are a number of "alternative" treatments that have no significant demonstrated physical benefit in a majority of cases.  But they don't cause any harm either, and might provide some relief at the emotional level.  They include massage, ultrasound, electrical stimulation, acupuncture and other techniques.

Only in the most severe chronic cases will medical professionals recommend the most aggressive treatments, such as surgery. Surgery usually is considered only when:

  • Many other non-surgical treatments have been tried and failed
  • The surgeon believes the procedure will have a good result
  • The patient agrees to an invasive procedure that isn't guaranteed to work
  • Everyone's decision is being made rationally and not under stress

The most common surgery for chronic back pain is spinal fusion – basically, turning the painful area of the spine into a solid, immovable piece of bone.  The theory is simple:  If it isn't moving, it shouldn't hurt.  The procedure involves a bone graft or bone substitute to fuse two vertebrae together.  This is a major invasive procedure that can take a year or more to recover from.  But back pain can be greatly reduced unfortunately, it is rarely completely eliminated.

One technique new to the United States – but practiced in Europe for several years – is disc replacement surgery.  It involves removing a degenerated disc and replacing it with an artificial component – similar to knee or hip replacement surgery.  It has the benefits of maintaining flexibility and requiring a shorter recovery time.

Whatever treatment is used, people who recover from back pain should take steps to prevent its recurrence.  People who never have suffered an episode of back pain should take steps to ensure they never do.  Preventative measures include:

  • Exercise / stay active
  • Lose weight
  • Stop smoking
  • Get help when lifting a heavy or awkward object
  • Lift using your leg muscles, not your back
  • Avoid standing for long periods of time  (use a stool, shift from foot to foot)
  • Don't wear high heels
  • Use cushioned soles when walking
  • Use a work chair with a straight back, adjustable seat, back and armrests, and a swivel seat
  • Sit with your knees higher than your hips  (use a stool)
  • Place a pillow or other lumbar support behind your lower back while sitting or driving
  • Break up long drives by stopping often and walking around

Even for serious cases, a combination of proven treatments and good follow-up preventative care can relieve most cases of back pain, restore normal function / mobility, and help reduce recurrences.

Medline Plus

Medline Description: 

Conduct an off-site search for Back Pain information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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