NW Spine - Library

by Greg E. Bradley-Popovich, DPT, MSEP, MS, CSCS

© 2000

A recent visit to the bookstore revealed dozens of book titles on the subject of back pain. I found back-pain books for dummies, idiots, and camels (a two-volume set). This abundance of books is not surprising given the large number of people who suffer from this pesky and sometimes debilitating disorder. Opinions on back pain are many and varied, and are just like the proverbial belly button in that everyone has one. Even experts cannot always agree on the cause and treatment of back pain. While I do not claim to have a cookie-cutter solution for back pain, I do hope to provide readers with sound advice for nearly any person with back pain who is otherwise healthy.

Given the volumes that have been published on the subject of back pain, I obviously cannot address every aspect of this topic or cure a person over the Internet. In fact, it would be irresponsible for me to attempt to treat patients without ever having examined them. But, perhaps this article will assist you in not exacerbating your condition and buying you time until you can seek the advice of a qualified health-care professional. Or, if you are one of the minority who has not suffered back pain, then perhaps the following suggestions herein will help keep you pain-free.

There are a variety of problems that may arise in the back. This is partly due to numerous anatomical structures involved in the function of the spine and those structures that lie in close proximity to the spine. The spine is typically composed of 26 individual bones called vertebrae (singular--vertebra). These vertebrae have 103 joints that connect themselves to one another, to the ribs, to the skull, and to the pelvis. There are 23 spongy disks between the vertebrae of the neck, mid-back, and lower back, with 31 pairs of spinal nerves emerging between the vertebrae and through the openings in the fused vertebrae of the sacrum (the bone just above the tail bone). In addition to nerves, some blood vessels also pass between vertebral openings (Homola, 2000). The number of muscles involved in orchestrating spinal movement is equally impressive, with dozens upon dozens of muscles attaching to the vertebrae either directly or indirectly.

Disks can bulge or herniate, joints can become arthritic, bony openings may narrow, nerves and blood vessels can become crowded, joints may be sprained, and muscles may spasm. No wonder the exact cause of back pain is so often elusive! Let’s not forget that more than one problem may be at the center of back pain in a given individual. Also, pain may be present in perfectly healthy tissues from movement dysfunction alone (i.e., abnormal movement is uncomfortable but doesn’t produce tissue damage) (Waddell, 1998). While much of this article’s content can be applied to the entire spine, this article was written with low back pain in mind because it comprises the majority of back pain.

In addition to the many possible things that can go wrong with your back anatomically, another avenue for back pain has been proposed: your mind. This certainly is not to say that back pain is all in a person’s head, because the pain is real. However, some back pain experts believe that the severity of symptoms depend greatly on a person’s psyche (Ljunggren, 1993; Sarno, 1991). One unconventional back pain guru suggests that most back pain in America is due to what he refers to as "tension myositis syndrome," which is the physical manifestation of emotional stress (Sarno, 1991).

Wouldn’t it be great if we possessed certain criteria by which we could predict who would develop back pain? Unfortunately, no such crystal ball exists for spinal disorders. Even the most fundamental characteristics of the back, such as strength, have not historically been easy to interpret. For example, we may commonly think that a weak back contributes to back pain. However, some research shows that sometimes stronger persons are more prone to back pain, perhaps because such heathens heave things around without attention to proper technique or they are more likely to lift things for which other mortals would be tempted to enlist the services of a forklift (Ljunggren, 1993). Some studies have found that the average trunk (back + abdominal) strength for back pain patients is less than for pain-free persons, but some studies have not shown this (Ljunggren, 1993). Confusing, isn’t it? One reason for such confusion is that until the advent of very sophisticated testing equipment, researchers and clinicians could only estimate gross truncal strength, which included a combination of hamstring, buttock, and low back muscular effort. What has become obvious through recent studies is that for measures of strength to correlate with back dysfunction, crude measuring tools will not suffice. Rather, low back strength must be tested in an isolated fashion without the confounding substitution of other muscles. I am aware of only one type of equipment capable of accurately assessing low back strength (MedX of Ocala, FL).

What about the ratio of strength between the back and abdominal musculature? We’ve all heard the common advice that our abs are too weak if we have back pain. This may be true for some but not all back pain sufferers (Kendall, McCreary, Provance, 1993). Most researchers have found the back muscles to be weak relative to the abdominal muscles in those with back pain (Ljunggren, 1993). In general, the back muscles should be about 30% stronger than the abdominal muscles in bending the spine, a determination that can be made by a well-equipped physical therapy clinic (Ljunggren, 1993). One study found an interesting association: back pain that radiates down the leg was associated with relatively weak back muscles while weak abdominals were associated with back pain during exercise or work (Ljunggren, 1993). Nevertheless, most contemporary back pain researchers recognize the muscles surrounding the spine to be both the muscles most affected by back pain as well as the key muscles to be trained in the resolution of back pain. In addition to strength deficits, a lack of endurance in the spinal muscles is also associated with back pain (Ljunggren, 1993). The major shortcoming of the strength/endurance research regarding back problems is that it does not address the issue of the chicken or the egg. Simply put, did the trunk muscles become deconditioned or imbalanced due to back pain and resultant inactivity, or did unfit trunk muscles lead to back pain? Whether causative or merely a consequence, what we do know is that weakness of the spinal musculature is an abnormality that should be addressed. In addition, pain itself is a strong inhibitor of muscle contraction (Ljunggren, 1993). Interestingly, certain back muscles have been shown to shrink by 30% in persons with prolonged back pain (Waddell, 1998). Adding to the complexity of strength in back pain, evidence correlating back pain with deficits in gluteal and quadricep strength has recently emerged.

The list of risk factors for back problems is long. Possible risk factors for back pain, back injury, and back-related disability--some of which are debatable--include the following (Adapted from APTA, 1997; Jones, 1993; Kendall, McCreary, Provance, 1993; Ljunggren, 1993; Waddell, 1998):

weak or easily fatigable trunk muscles

muscle imbalance

excessive body weight

pregnancy (temporary)

leg-length discrepancy

habitual suboptimal body mechanics

poor posture

substance abuse, including smoking

inflexibility of trunk muscles

heavy occupational demands, including lifting, twisting, sitting, and driving

poor work satisfaction

prior history of back problems

psychological distress

physical unfitness

male gender

age (peak occurrence 40-60 years of age)

Admittedly, many of the associations between these risk factors and back problems are very weak. Other contributing factors to general musculoskeletal injury with resistance exercise include anabolic steroid use, poor lifting technique, and skeletal immaturity (Reeves, Laskowski, & Smith, 1998a) It is my belief that when you combine several of these factors together, symptoms are more likely to appear. Fortunately for you and your back, several of the above risk factors are modifiable. For example, a qualified exercise physiologist or physical therapist could design a general conditioning program for cardiorespiratory fitness and weight loss. A physical therapist, for instance, could offer specific exercises to safely strengthen the trunk muscles and perform a work-site assessment to make hard labor less taxing.

For those individuals who are between bouts of back pain, what can be done to avoid another episode? Of course one can enlist a qualified health care provider for interventions as well as modify some risk factors. The good news is, the longer the time between episodes of back pain, the less likely you are to have another bout (Waddell, 1998). The bad news is that two-thirds of patients haven’t a clue as to what triggers their back pain (Waddell, 1998), and those who do claim to know the cause of their back pain may attribute it to an unrelated activity, just for the sake of attributing it to something.

Obviously, the deadlift, stiff-legged-deadlift, squat, seated cable rows, and good-mornings can be dangerous to the spine, particularly if poor technique is employed. Other lifts that may be related to back pain are the military press and bench press (Reeves, Laskowski, & Smith, 1998b). Several resources demonstrating proper technique are available. I do not wish to reinvent the wheel, however, a widely applicable guideline is to avoid flexing (forward bending or slouching) of the spine while lifting. It is not recommended to excessively flex the lumbar spine while under load, and those who engage in resistance exercise are commonly instructed to maintain a neutral or lordotic (concave) lumbar spinal curvature during such lifting activity (Friday, 2000; Harman, 1994). However, there remains considerable disagreement as to which of these lifting forms is best, and it may be an individual consideration based on several factors (Kendall, McCreary, Provance, 1993).

I contend that one of the most dangerous lifts performed in the gym is simply the removal and replacement of free-weight plates. For example, 45 pound plates are often kept on the lowest peg of the weight tree, but how often do you see someone bend their knees and keep a neutral spine while the plate is placed on the tree?

Between intense sets of exercise and among distractions such as conversation, fatigue, and scantily clad members of the opposite sex, we often are not conscious of our lifting technique during the mundane chore of racking weights or loading bars. Worse yet, it is not uncommon to see lifters grab a plate off one exercise apparatus and then to twist and rack the weight or place it on the next exercise station. A congested gym with insufficient spacing of equipment promotes this poor form because it may not allow room to actually turn the whole body 180 degrees so that the feet and the trunk move as a unit. No, I am not accusing you of having a wimpy back. However, it is believed that most herniated disks result from years of abuse that results in microtears eventually leading to rupture. The movement most blamed for these microtears is lifting while twisting the spine, which places shear stress on the outer connective tissue fibers of the disks. Twisting, or torsion, of the spine is also suspected to be injurious due to its effects on the joints of the lumbar spine. Thus, twisting may lead to disk and/or joint damage in the lower spine (Farfan, 1983). If only folks applied the same caution and attention to biomechanics as they do when performing a particular exercise!

The best treatise to date that I have seen on the subject of lifting belts was authored by Paul Chek. I highly recommend his articles for anyone interested in a detailed, well-referenced examination of spinal/trunk anatomy, kinesiology, and the use of a weight belt. In sum, Chek argues that weight belts are simply not effective at preventing injury and may actually result in faulty muscle recruitment patterns and weakness of the trunk muscles (2000a & b). I agree.

In addition to Chek’s concerns regarding reliance on belts, I hypothesize that using a belt could increase the chances of inguinal (groin) hernias in males. An inguinal hernia occurs when a loop of intestine sneaks into the scrotum. So what’s the connection between using a belt and crowding the family jewels? Believe it or not, gentlemen, your little testosterone-producing gonads once resided in the abdominal cavity. While still in the womb or soon after birth, the testicles descend through little tunnels into the scrotum where they can better be temperature regulated to optimize sperm production and lifespan. The problem is that if the tunnels remain partially open, or patent, then an avenue exists for other viscera such as the intestines to communicate with the scrotum. Hernias may also push their way through weaker structures in the lower abdominal area with the same unpleasant result (Moore, 1992).

Now, imagine wrapping a tight, supportive weight belt around your waist to greatly increase abdominal pressure for spinal support during lifting. My belief is that if someone is predisposed to an inguinal hernia, then very high intra-abdominal pressure combined with the rigidity of a weight belt encourages the pressure to follow the path of least resistance (i.e., through the tunnels into the scrotum). A useful analogy is that of a balloon entirely wrapped in duct tape except for a small area that remains uncovered. If you continuously inflate the balloon, the area most likely to pop is the one with the least support. To check on a hernial predisposition or a hernia in the making, next time you have a physical or are seeing the family practitioner, perhaps you should inquire about the old turn-your-head-and-cough test.

If you have a history of regular back pain, something is wrong with your back, although it may be as simple as normal tissue being exposed to prolonged abnormal stress, as is the case with poor sitting posture. The nature of the exact cause of the pain may be elusive and may not show up even with medical imaging techniques such as MRI, but obviously pain is a sign that something is not right. Rather than ignoring the pain until resolution of symptoms occurs, consider getting professional help to possibly shorten the current episode and to decrease the occurrence of future episodes. (In rare instances it is now believed that some persons may continue to experience pain in the absence of any anatomical defect due to a perpetual pain cycle that is caused by a sensitization of the nervous system. This theoretical explanation for chronic pain is like the repeated messages of a broken record, with the needle stuck in a groove.)

Not so long ago, bed rest was common medical advice for someone suffering a bout of back pain. However, we now know that being a sloth is generally not what is best for the patient. First, lying around in bed will make you out of shape in very short order, and this deconditioning can result in some potholes on the road to recovery (Ljunggren, 1993). Second, lying around will make the spine stiff and possibly more painful with movement (Saunders & Saunders, 1993). Third, the intervertebral disks rely on loading and unloading (i.e., movement) for nourishment (Ljunggren, 1993). Fourth, loafing around may result in isolation and depression (Waddell, 1998). Need I go on? Ample research shows that bed rest is an ineffective method of back pain relief, but it is very effective at making one out of shape (Waddell, 1998).

There are many activities that can still be performed by a person suffering from a bout of back pain. If you’ve been on an extended training hiatus and have not been physically active, it is best to resume exercise gradually. Consider several walks per day to combat deconditioning (Ljunggren, 1993), provided that walking does not significantly worsen your symptoms. Actually, the majority of persons with back pain get relief from standing and walking. Cycling and swimming may also be tolerable (Oldridge & Stoll, 1997). Exercise aside, try to continue with as many of your typical daily activities as possible (Waddell, 1998). Try to maintain good posture and do not allow the body to become biomechanically distorted from the pain (Saunders & Saunders, 1993; Waddell, 1998).

Several over-the-counter medications may be helpful in battling back pain. No drug should be used simply to kill pain while a person vegetates. Rather, pain relief through medication should be used to allow more normal activity and proper posture (Waddell, 1998). Over-the-counter analgesics such as acetaminophen, aspirin, and ibuprophen may be helpful, and the latter two also possess anti-inflammatory properties to decrease swelling that could otherwise lead to stiffness and additional pain.

I don’t want to excessively influence the reader with my own biases, but I think it only makes sense that patients should play an active role in their own rehabilitation. I am for patient empowerment! Thus, I do not recommend relying solely on the scalpel of the surgeon, pain meds or muscle relaxants prescribed by the physician, spinal adjustments performed by the chiropractor, or the thermal or electrical modalities of the physical therapist. Many health-care professionals are guilty of treating the symptoms and ignoring the underlying dysfunction (Saunders & Saunders, 1993; Waddell, 1998). Only by making the necessary lifestyle changes such as correcting poor posture and using good body mechanics can you expect to enjoy optimum back health (Kendall, McCreary, Provance, 1993). Share in the responsibility for your health and don’t let others determine your destiny! Doing so will save you and/or your insurance carrier substantial money in addition to preventing dependence on a particular health care professional who may be able to offer only short-term relief without your active participation.

Perhaps even more important than what you should do in the management of your back pain is what you should avoid. If your back pain is very severe, it is probably best to avoid strength training, particularly if the back pain radiates down the back of the thigh (Ljunggren, 1993). This is especially true of free weights, though select strengthening machines that provide ample stability and protection for the spine can be continued. You may want to avoid jarring activities such as running (Oldridge & Stoll, 1997). Avoid any activity that worsens your symptoms, such as prolonged sitting which bothers many persons with back pain (Ljunggren, 1993) or some types of exercise (Oldridge & Stoll, 1997), particularly if increased symptoms persist for more than a few minutes following the exercise (Saunders & Saunders, 1993). Be especially aware of any lifting around the workplace or home. Avoid heavy lifting or bending and twisting the back during lifting (Oldridge & Stoll, 1997).

One of the most common questions I am asked by those suffering back pain is whether they should apply heat or cold to the area. If the injury or current episode of back pain has occurred within the last 48 hours, then cold is probably the best policy because cold induces vasoconstriction to decrease swelling. Cold also decreases pain and muscle spasm, thus facilitating more normal movement patterns. Sorry, the recommendation of cold during the first two days post-injury also excludes the use of a hot tub or hot showers during this period. Ice may be applied as an ice pack for 15-20 minutes or as ice itself for 3-5 minutes (Von Nieda & Michlovitz, 1996). Raw ice rubbed in a circular pattern, or ice massage, is particularly useful if the point of pain is small and specific, and it is faster than an ice pack. Ice massage is messier than packs and lends itself well to being performed immediately before stepping out of the shower to dry off. A gel ice pack is preferred over the hard variety because it conforms to the anatomy. A homemade gel pack requires a ziplock bag filled with one part alcohol to three parts water. Another alternative ice pack is a bag of frozen peas, corn, etc.

Heat, like cold, can also decrease muscle spasm and pain. The main distinction between heat and cold is their effects on blood flow. Heat can be used two days post-injury because it will vasodilate the area of application to increase blood flow, which flushes out any waste products that have accumulated and brings in nutrients to facilitate repair. By changing the properties of connective tissue, joints may feel less stiff following heating. Electric or microwaveable heating pads or hot baths may be used as a thermal modalities, and the period of application is typically 20 minutes (Rennie & Michlovitz, 1996). If in doubt about the inflammatory nature of an episode of back pain, it may be best to err on the side of cold so as to not increase the inflammation.

*Please follow the manufacturer’s instructions on any thermal devices as to avoid any burns or frostbite.

If you are currently experiencing back pain, chances are it will get better (Waddell, 1998). A low-back pain episode typically resolves itself after about two months in 90% of people afflicted, regardless of treatment (Ljunggren, 1993). One-third of patients will be pain free one month after the onset of back pain, and an episode of back pain lasts only a few days in half of those with back pain (Waddell, 1998). Based on such data, a common misconception on the part of many health care professionals and patients alike is that if you can just wait it out, the symptoms will go away. For example, I once attended a conference on back pain where the general message was to leave most patients alone because their symptoms would subside in a few weeks anyway. But, just because the symptoms disappear does not mean that the underlying problem has spontaneously healed itself (Saunders & Saunders, 1993). Therefore, a much better approach to addressing back pain is to seek intervention during the episode and continue the prescribed treatment indefinitely to reduce the occurrence of future episodes, especially given that up to 89% of folks who have experienced back pain once will have subsequent bouts of back pain (Waddell, 1998). An unfortunate 5% of patients will have back pain for greater than 6 months, and 2% will virtually have it for life (Ljunggren, 1993).

Regardless of the cause of back pain, there are many instances where the exact pathological diagnosis won’t necessarily affect treatment (Saunders & Saunders, 1993; Waddell, 1998). I used to think otherwise, believing that to treat the problem you had to precisely understand the underlying condition. However, I have since seen the marked improvement of many patients with an unknown cause of back pain. This is possible because many conditions have certain factors in common, such as poor posture, muscle weakness, inflammation, stiffness, and muscle splinting. It has been suggested that addressing the patient’s symptoms, particularly abnormal movement, is much more critical than determining what is wrong anatomically (Waddell, 1998). By the way, it’s important to know that medical imaging (X-ray films, MRI, CT scans, etc.) often presents misleading findings of abnormalities that are simply coincidental and unrelated to the back pain (Saunders & Saunders, 1993; Waddell, 1998)—normal abnormalities, if you will.

According to the American Physical Therapy Association, about 80% of patients suffering from typical spinal disorders without fractures, such as disk herniation/deterioration, bony narrowing, nerve root compression, and vertebral slippage, reach the desired outcome in 8 to 24 visits (1 to 6 months) per episode of care (APTA, 1997). Obviously, the expected course and duration of treatment vary with the pathology itself and other influences such as age, attitude, lifestyle, etc.

Some readers may be disappointed that this article did not offer specific advice for self-diagnosis or self-treatment of back pain. It is important to realize that although back pain is usually benign, sometimes back pain may be the manifestation of a serious--even life-threatening--condition. Case-in-point is a pharmacy student at my alma mater who a few years ago had suffered from low back pain for some time. One day following an exam, he collapsed outside a classroom--dead. An abdominal aortic aneurysm had ruptured. Please, take back pain seriously and seek qualified help, particularly if your symptoms are severe, pain is preventing you from performing normal activities, or pain persists after a few days (US Agency for Health Care Policy and Research in Waddell, 1998). If you develop bladder/bowel changes, numbness between your legs, or extreme leg weakness, consider it an emergency and seek immediate attention (US Agency for Health Care Policy and Research in Waddell, 1998). Fortunately, for the vast majority of those with back pain, chances are that your back pain is nothing serious and you will have a speedy recovery if you actively participate in your therapy.

Dr. Greg Bradley-Popovich holds dual master's degrees in Exercise Physiology and Human Nutrition from West Virginia University as well as a doctorate in Physical Therapy from Creighton University. He is the Director of Clinical Research at Northwest Spine Management, Rehabilitation, and Sports Conditioning in Portland, Oregon.

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