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Harvard Commentaries
35320
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Low-Back Pain


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School


If your back aches, you're not alone. In fact, 70% to 80% of American men will experience low back pain. Back pain is the fourth most common reason people seek medical care. And it's also expensive, running up a tab of over $50 billion annually in the United States.

Back aches are common, painful, and expensive — but they're rarely serious. Half the episodes resolve in less than a week, and three-quarters are gone in a month.

If you've found a way to live with your back, don't change a thing. But if you need more help, here are some practical answers to common questions.

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The Normal Back

Like every part of the human body, the back is complex. Your "backbone," of course, is not a bone at all but a column of 24 individual bones, the vertebrae. These bones are separated by intervertebral discs, which act as shock absorbers. Each disc has a soft core surrounded by a capsule of fibrous tissue. Nerve roots run out from the spinal cord, passing between the vertebrae. These spinal nerves transmit the commands responsible for muscle movement, and they carry back the signals of sensation.

A group of sturdy ligaments holds the vertebrae together, and strong muscles run along the sides of the spinal column to provide additional support. The abdominal, pelvic, and hip muscles help maintain the normal curvature of the back and support a share of the body's weight.

What Causes Back Pain?

There are almost as many explanations for back pain as there are backs. The most common reasons are:

  • Muscle spasms and strains
  • Bulging discs
  • Pinched nerves
  • Sciatica
  • Arthritis

Poor posture, tight muscles and abnormal alignment of the spine follow closely behind. More serious problems, such as osteoporosis, compression fractures, tumors and infections are much less common. And truth be told, in most cases, the exact cause of back pain remains a mystery.

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When Is Back Pain Serious?

Pain is always serious to the person suffering, but it doesn't necessarily indicate a major medical problem. Whether your pain is severe or mild, it calls for medical evaluation and care when you have any of these warning signs:

  • Pain that started before age 20 or after age 55
  • A recent major trauma, such as a motor vehicle accident, fall, or severe sport injury
  • Pain that radiates down a leg, particularly if accompanied by:
    • Numbness or loss of sensation
    • Weakness or loss of muscular strength
    • Impaired bowel or bladder control
  • Pain that is constant and does not vary with motion
  • Pain in the upper back or chest
  • Pain that increases at night or when lying down
  • An unexplained fever of 101° or more
  • An unexplained weight loss of 10 pounds or more
  • A previous diagnosis of cancer or another major illness
  • Use of steroids or other drugs that block the immune system
  • A history of drug abuse

You should see a doctor without delay if you have any of these warning symptoms. But if you have garden-variety back pain, you may be able to handle it on you own.

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Should I ...

  • ...stay in bed? You may have to rest in bed while your pain is at its worst, but get up as soon as you can. Staying down won't speed your recovery, and it's bad for overall health. Use common sense. Be as active as your pain will allow, but don't push too hard. Avoid heavy lifting, bending and twisting, and prolonged sitting. When you rest, lie on a firm surface, such as a good mattress, a mattress with a bed board under it or the floor. Use a heating pad if it makes you feel better. Pick a chair with good low-back support. As you improve, spend less time resting, and more time standing and walking.
  • ...do back exercises? Back exercises are not helpful for acute low-back pain. But after you recover, they may help you prevent future episodes. Although there is little scientific proof of efficacy, it's reasonable to start exercises two to three weeks after your back feels better.
  • ...see a doctor? If you have any of the warning symptoms listed above, the answer is yes. For ordinary back pain, however, the choice is yours. It's certainly reasonable to begin by taking care of yourself. But if your pain persists for four to six weeks, you should see your primary care doctor. Unusual or difficult conditions may require an orthopedist, neurologist or neurosurgeon.

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Can Medication Help?

Medication won't speed recovery, but it can take the edge off the pain and help you get up and around. For ordinary low-back pain, you can treat yourself with non-prescription drugs. Use only what's necessary. Start with a simple pain reliever like acetaminophen. It's not as strong as some other medications, but it has fewer side effects. Don't take more than 1,000 milligrams four times a day. (Exceeding 4,000 milligrams (4 grams) in 24 hours can injure the liver.)

Most doctors recommend a nonsteroidal anti-inflammatory medication (NSAID) as the next treatment. You can try a non-prescription product such as aspirin, ibuprofen or naproxen, or you can ask for one of the many prescription NSAIDs. Stronger prescription painkillers and narcotics are rarely needed. If you have intense muscle spasms, your doctor may prescribe a muscle relaxant, such as diazepam, cylobenzaprine, carisoprodol, or methocarbamol. Finally, an anti-seizure medication, such as gabapentin, may help relieve the nerve pain from sciatica; doctors can prescribe it for this purpose even though the U.S. Food and Drug Administration (FDA) has not approved it for this use.

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What About...

  • ...X-rays or lab tests? Spinal X-rays are simple and relatively inexpensive, but they are rarely useful. Trekking to a facility for X-rays when your pain is at its peak is likely to do more harm than good. But if your pain hangs on for four to six weeks, your doctor may order a series of X-rays along with a few simple lab tests, such as a complete blood count, erythrocyte sedimentation rate (ESR) and urinalysis. More elaborate tests are rarely helpful for ordinary, acute low-back pain.
  • ...a CT scan or MRI? Computed tomography (CT) scanning is a powerful imaging technique, but for back pain, CTs are not as good as MRIs. In general, CTs should be used only when detailed imaging is necessary and MRIs cannot be performed. Magnetic resonance imaging (MRI) provides a superb look at the back, including the vertebral bones and joints, the discs and the nerve roots. MRIs are safe, but not for men with pacemakers or certain metallic implants. MRIs have some drawbacks. They are expensive and they can trigger claustrophobia. Because they take time, they may be hard for people who cannot lie still because of pain. Also, they can be too sensitive. They often discover bulging discs in people who don't have any back problems. If these people complained of back pain, doctors would be tempted to blame it on disc disease, which could lead to unnecessary invasive therapy. MRIs are not needed for uncomplicated low back pain, but they can be very important for patients with warning signs or with pain that's prolonged or unusually severe. In most cases, MRIs should be performed only if surgery is a serious consideration.
  • ...a chiropractor? Chiropractors and doctors of osteopathic medicine (D.O.s) generally recommend spinal manipulation for back pain, but most M.D.s are skeptical. Before you try manipulation, be sure you don't have any of the warning signs listed above. Remember, too, that most acute low-back pain will resolve without special treatment, and that physical therapists are an excellent resource for pain that doesn't resolve on its own. With these constraints, manipulation therapy is an understandable choice for men with chronic pain who feel it's worth their time and money.
  • ...a back brace? Wearing a lumbosacral support ("back brace" or "corset") for acute low-back pain is one of the many traditional treatments that have not stood the test of careful scientific studies. In fact, there is some concern that a support may produce muscle weakness and stiffness. If you choose to use a support, wear it only when you think it will do the most good. Once your pain has settled down, keep your back flexible and strong with an exercise program.

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What Other Treatments Are Available?

Although most acute low-back pain will resolve with a simple, conservative, self-help program, some people require additional therapy for difficult or chronic pain. A physical therapy-rehabilitation program can be very helpful. It typically begins with an exercise program and adds modalities, such as heat or cold treatments, ultrasound, traction or electrical stimulation.

If physical therapy doesn't do the trick, doctors may treat selected patients by injecting steroids into the painful area.

People with complicated back pain (see warning signs) may need surgery, but it should be the last resort for uncomplicated pain. If a herniated lumbar disc is the cause of pain, a lumbar discectomy is usually the preferred approach. Laser surgery, endoscopic procedures and other less invasive operations are being used, but experience with them is limited.

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How Can I Keep My Back Healthy?

Keep your back flexible and your abdominal muscles strong. Good posture and body mechanics are essential. In particular, be careful when you lift. Get help if an object is too heavy for you to lift comfortably. Keep heavy objects close to your body, and be sure to bend your knees and lift with your legs, not your back.

A good mattress and supportive chairs also make sense. But the best way to prevent back pain is to keep the rest of your body healthy. Aerobic conditioning is the key. Active, fit men have less back pain than sedentary, out-of-shape gents. Swimming, walking and biking are particularly desirable for those who've had back pain in the past. A good diet will also help — not by nourishing bones and joints, but by preventing obesity. The old-time docs had it right when they said you can never be too thin for your back.

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Back to Basics

Because it's so common, back pain is a hot topic for both health care professionals and the general public. Everyone with a back, it seems, is an expert. Programs for prevention spark debate, theories about causation ignite controversy and treatment plans start wars. Listen to the options and then decide what's best for you. For most men, a simple self-help program will control acute low-back pain. But whether you treat yourself or get professional help, you should always listen to your body and stay alert for the warning signs that could indicate serious trouble. Fortunately, such warnings are uncommon. For most men, basic care will banish backaches.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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