Back Pain | How to Eliminate and Treatment Back Pain?

A. What Are the Causes of Back Pain?

It is important to understand that back pain is a symptom of a medical condition, not a diagnosis itself. Medical problems that can cause back pain include the following:

Mechanical problems: A mechanical problem is a problem with the way your spine moves or the way you feel when you move your spine in certain ways. Perhaps the most common mechanical cause of back pain is a condition called intervertebral disc degeneration, which simply means that the discs located between the vertebrae of the spine are breaking down with age. As they deteriorate, they lose their cushioning ability. This problem can lead to pain if the back is stressed. Other mechanical causes of back pain include spasms, muscle tension, and ruptured discs, which are also called herniated discs.

Injuries: Spine injuries such as sprains and fractures can cause either short-lived or chronic pain. Sprains are tears in the ligaments that support the spine, and they can occur from twisting or lifting improperly. Fractured vertebrae are often the result of osteoporosis, a condition that causes weak, porous bones. Less commonly, back pain may be caused by more severe injuries that result from accidents and falls.

Acquired conditions and diseases: Many medical problems can cause or contribute to back pain. They include scoliosis, which causes curvature of the spine and does not usually cause pain until mid-life; spondylolisthesis; various forms of arthritis, including osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis; and spinal stenosis, a narrowing of the spinal column that puts pressure on the spinal cord and nerves. While osteoporosis itself is not painful, it can lead to painful fractures of the vertebrae. Other causes of back pain include pregnancy; kidney stones or infections; endometriosis, which is the buildup of uterine tissue in places outside the uterus; and fibromyalgia, which causes fatigue and widespread muscle pain.

Infections and tumors: Although they are not common causes of back pain, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis, or when they involve the discs that cushion the vertebrae, which is called discitis. Tumors, too, are relatively rare causes of back pain. Occasionally, tumors begin in the back, but more often they appear in the back as a result of cancer that has spread from elsewhere in the body.

Although the causes of back pain are usually physical, it is important to know that emotional stress can play a role in how severe pain is and how long it lasts. Stress can affect the body in many ways, including causing back muscles to become tense and painful.

B. What is The Risk Factor of Back Pain?

Factors that increase your risk of developing low back pain include:

• Smoking
• Obesity
• Older age
• Female gender
• Physically strenuous work
• Sedentary work
• Stressful job
• Anxiety
• Depression

C. Treatment and Drug for Back Pain

Most back pain gets better with a few weeks of home treatment and careful attention. A regular schedule of over-the-counter pain relievers may be all that you need to improve your pain. A short period of bed rest is okay, but more than a couple of days actually does more harm than good. If home treatments aren't working, your doctor may suggest stronger medications or other therapy.

Medications for Back Pain
Your doctor may prescribe nonsteroidal anti-inflammatory drugs or in some cases, a muscle relaxant, to relieve mild to moderate back pain that doesn't get better with over-the-counter pain relievers. Narcotics, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.

Low doses of certain types of antidepressants — particularly tricyclic antidepressants, such as amitriptyline — have been shown to relieve chronic back pain, independent of their effect on depression.

Physical therapy and exercise
A physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation and muscle-release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques will help prevent pain from coming back.

Injections
If other measures don't relieve your pain and if your pain radiates down your leg, your doctor may inject cortisone — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots, but the pain relief usually lasts less than six weeks.

In some cases, your doctor may inject numbing medication into or near the structures believed to be causing your back pain. Early studies indicate that botulism toxin (Botox) also may help relieve back pain, perhaps by paralyzing strained muscles in spasm. Botox injections typically wear off within three to four months.

Surgery
Few people ever need surgery for back pain. There are no effective surgical techniques for muscle- and soft-tissue-related back pain. Surgery is usually reserved for pain caused by a herniated disk. If you have unrelenting pain or progressive muscle weakness caused by nerve compression, you may benefit from surgery. Types of back surgery include:

• Fusion. This surgery involves joining two vertebrae to eliminate painful movement. A bone graft is inserted between the two vertebrae, which may then be splinted together with metal plates, screws or cages. A drawback to the procedure is that it increases the chances of arthritis developing in adjoining vertebrae.
• Disk replacement. An alternative to fusion, this surgery inserts an artificial disk as a replacement cushion between two vertebrae.
• Partial removal of disk. If disk material is pressing or squeezing a nerve, your doctor may be able to remove just the portion of the disk that's causing the problem.
• Partial removal of a vertebra. If your spine has developed bony growths that are pinching your spinal cord or nerves, surgeons can remove a small section of the offending vertebra, to open up the passage.

resource: Mayo Clinic

D. Prolotherapy

Prolotherapy (also called sclerotherapy) involves injecting painful ligaments and tendons with sugar solutions that are intended to stimulate production of connective tissue. The theory is that prolotherapy can strengthen these ligaments and tendons, and reduce pain. Studies of prolotherapy have reported conflicting evidence regarding its effectiveness in treating chronic back pain.

A review of five well-designed studies involving 366 participants concluded that prolotherapy alone was ineffective in treating chronic low back pain. However, when combined with other treatments — such as spinal manipulation and exercise — prolotherapy may improve chronic low back pain.

A typical course of prolotherapy treatment is six to 10 sessions, sometimes with multiple injections at each session. Prolotherapy is known to cause some pain at the injection site, but this is typically mild and temporary. As with any injection, there is a risk of infection, bruising, bleeding or tissue damage.

More research is needed to clarify what role, if any, prolotherapy plays in the treatment of chronic low back pain.

E. Disk Replacement

Disk replacement is a relatively new treatment option for degenerative disk disease. In this procedure, the damaged disk is removed and replaced with a metal and plastic disk.

Disk replacement appears to be as effective as spinal fusion in relieving low back pain. However, as with all emerging treatments, the indications for its use are still very limited.

Ideal candidates for disk replacement surgery:

• Are between the ages of 20 and 60 years
• Have only one degenerated disk
• Have failed to respond to other forms of treatment
  

Disk replacement surgery isn't recommended for people who have systemic bone disease, such as osteoporosis, or who have had previous back surgery, including spinal fusion.
It's important to note that disk replacement surgery is more difficult than spinal fusion surgery. Also, the risks of removing the artificial disk if it fails or becomes infected are potentially serious.

By : Mayo Clinic neurologist Jerry Swanson, M.D.

F. Inversion Therapy

Inversion therapy is often promoted as a therapy for back pain. But there's no scientific evidence that it provides long-term pain relief.

Inversion therapy involves hanging upside down — supported by your ankles — to allow gravity to naturally decompress disks and nerve roots in your spine. Another form of inversion therapy entails lying on a table (inversion table) that gradually tips you head down — again, supported by your ankles.

Inversion therapy is one example of the many ways in which traction — stretching the spine — has been used in an attempt to relieve back pain. But traction is falling out of favor with many in the medical community. Well-designed studies that have evaluated traction for back pain have found no significant long-term benefit.

However, some people find that traction provides temporary pain relief. Those with sciatica or a pinched nerve may find traction beneficial as part of a more comprehensive treatment program.

A potential problem with inversion therapy is that it may significantly increase blood pressure in your head. For this reason, you should not try inversion therapy if you have heart disease, high blood pressure or eye diseases, such as glaucoma, or if you are pregnant.

By : Mayo Clinic neurologist Jerry Swanson, M.D.

G. Noninvasive Treatment

The goal of noninvasive treatment for back pain is twofold:

• Reduce but not necessarily eliminate your pain
• Help you improve your function so that you can resume as closely as possible your normal routine of work and leisure
  

After talking to you about the particular circumstances involving your back pain, your doctor may recommend one or more of the following common treatment options:

Back brace.

Many back braces or corsets (lumbar supports) are available without a prescription at pharmacies and medical supply stories. Or, your doctor may prescribe a specific brace customized for your back. The rationale behind braces is that they may support your abdomen and take some of the load off your lower back, they may restrict motion, and they may improve posture. But there's also concern that use of braces may result in the wasting away (atrophy) of some muscles that support the spine through lack of use. If you use a brace, limit the use to intermittently several hours a day. If you have a labor-intensive job that places stress on your lower back, a back brace or corset can help you when you first return to work after a back injury by avoiding too much strain on your spine.

Back braces and corsets may also make transitional movements — such as from a sitting to a standing position — more comfortable during an episode of back pain. There's insufficient evidence that back braces are more effective at relieving back pain than no treatment at all. The best course of action may be strengthening your trunk muscles to be the primary support for your back.

Pain medications.

You can take nonprescription medications, or your doctor may suggest prescription medications to relieve your discomfort until inflammation subsides and your body heals itself. Options include:

• Over-the-counter (OTC) analgesics. Analgesics are medications that relieve pain. They include nonsteroidal anti-inflammatory drugs (NSAIDs), counterirritants and topical analgesics. NSAIDs, such as aspirin, naproxen sodium (Aleve) and ibuprofen (Advil, Motrin IB, others), can relieve pain and reduce inflammation. Another option is counterirritants, which you apply to your skin as a cream or spray. These nonprescription medications — which include Bengay, Icy Hot and capsaicin (Zostrix) — stimulate your sensory receptors of heat or cold to cover up or counter pain. Counterirritant products may temporarily relieve chronic pain. Topical analgesics, many of which contain salicylates — the main ingredient in aspirin — also can reduce inflammation. NSAIDs appear to provide some relief for acute back pain, but evidence is still lacking regarding effectiveness of NSAIDs in chronic low back pain. In addition, though NSAIDs are widely used for treatment of low back pain, long-term use can have side effects, particularly effects on the gastrointestinal system and the kidneys.
• Anticonvulsants. Low doses of drugs more commonly used in the treatment of seizures and epilepsy are sometimes used to help people who have low back pain in conjunction with leg pain. These medications include gabapentin (Neurontin), topiramate (Topamax), clonazepam (Klonopin), carbamazepine (Carbatrol, Tegretol) and valproate (Depacon). These drugs aren't usually useful in treating low back pain. Instead, they're sometimes directed at treating the leg pain component in people who primarily have back pain associated with leg pain.
• Antidepressants. Some antidepressant medications, taken in lower doses than would be used to treat depression, may help in the treatment of low back pain. Antidepressants may work in a variety of ways. For example, they may result in a higher level in your brain of serotonin, a neurotransmitter associated with pain control. Antidepressants may also reduce anxiety and muscle tension. The evidence on the effectiveness of antidepressant medications in the treatment of low back pain is mixed. Among this group of medications, tricyclic antidepressants (TCAs) appear to be the most effective. They include such medications as nortriptyline (Aventyl, Pamelor), amitriptyline, desipramine (Norpramin), doxepin (Sinequan) and imipramine (Tofranil). Medications called selective serotonin reuptake inhibitors (SSRIs) don't appear to be as effective as TCAs for back pain.
• Opioids. In select cases, doctors may use certain narcotic medications (opioid analgesics) to treat low back pain. Examples of these medications include morphine (MS Contin, Oramorph SR, others), oxycodone (OxyContin), methadone (Dolophine HCL), fentanyl (Duragesic) and levorphanol (Levo-Dromoran). There is debate regarding the use of opioids, and they're not used as a long-term treatment. Among the reasons are side effects, as well as concerns about dependence. The most common side effects that limit their use include nausea and constipation, which can be severe. In addition, other common but less known important side effects include dizziness and sedation. Before your doctor prescribes opioids, have a thorough discussion with him or her about their benefits and drawbacks.
  

Cold or heat therapy.

Using cold and heat therapy may relieve pain and muscle tension in the initial days after back pain begins. Some studies show that heat is an effective approach for acute nonspecific back pain. As for chronic back pain, cold and heat likely won't cause harm and may be helpful, but there isn't scientific evidence at this time to prove that cold and heat are effective treatments for chronic low back pain. Cold or ice applied to your back can reduce inflammation and swelling by constricting blood vessels. The cold also acts to slow nerve impulses and make it less likely that your muscles will contract, in this way reducing pain.

To use cold packs, wrap an ice pack or a bag of frozen vegetables in a piece of cloth. Hold it on the sore area for about 15 minutes, several times a day. To avoid frostbite, don't place ice directly on your skin. Heat therapy increases blood circulation, which can aid healing of damaged tissues. Heat also allows tissues to stretch more easily, resulting in less stiffness, greater flexibility and less pain. To use heat therapy, take a warm bath, or use warm packs, a heating pad or a heat lamp for pain relief. Be careful not to burn your skin with extreme heat. If you find that cold provides more relief than heat, you can continue using cold packs, or try a combination of the two methods.

Electrical stimulation.

Transcutaneous electrical nerve stimulation (TENS) delivers a tiny electrical current to key points on a nerve pathway. The current, delivered through electrodes taped to your skin, isn't painful or harmful. It's not known exactly how TENS works, but it may stimulate release of pain-inhibiting molecules (endorphins) or block pain fibers that carry pain impulses. However, it's unclear whether those who benefit from TENS achieve relief by some direct effect on their nervous system or from the belief that they will benefit from the therapy (the so-called placebo effect). Some people with chronic pain use TENS to help them function with less discomfort. But several studies have concluded that TENS has not been proved effective in relieving chronic low back pain.

Exercise and physical therapy.

Physical activity plays a strong role in recovering from back pain and particularly in helping to prevent future pain and loss of function. Physical activity can include one or many among a wide range of exercises that you do in the presence of a physical therapist, or exercises that you do on your own at home. An exercise program can include any or all of the following components: flexing, stretching, endurance training, strength building and aerobic.

Supervised programs that include stretching and strengthening exercises, which don't specifically target the back, are more beneficial in relieving chronic low back pain and improving function. Your doctor or physical therapist can tailor an exercise program to meet your individual needs. There is no one-size-fits-all approach.

Exercise programs are individualized because people have different levels of pain and differing injuries that caused the pain initially. Exercise doesn't appear to increase your risk of future back injuries and may help prevent back pain at work. Benefits of a physical activity program may include:

• Pain reduction
• Strengthening of weak muscles
• Stretching of contracted muscles
• Decreasing mechanical stress on your back
• Improving your fitness to prevent injury
• Stabilizing your back
• Improving your posture
• Improving your mobility
• Decreasing the rate and severity of recurring back pain
• Allowing quicker recovery from future flares of back pain

Some studies suggest that exercise therapy is more effective than are conservative or inactive treatments in people with chronic low back pain. Short-term, modest improvements were seen in such areas as pain, disability, strength and flexibility. Exercise and physical therapy are an important part of your treatment program and should become part of your permanent routine at home. Improving the strength, endurance and function of your back helps minimize the chance of recurrence of back pain. One study showed that people who didn't exercise after an initial episode of acute low back pain were more likely to experience a recurrence of low back pain than were people in the study's exercise group. Mild discomfort that you may feel as you begin an exercise program should gradually ease as your muscles become stronger. The key is to start an exercise program at a low level to ensure your comfort and proper technique, and then progress slowly as your symptoms allow.

Cognitive behavior therapy.

This type of talk therapy combines attempts to identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. It's based on the idea that your own thoughts determine how you behave. Even if an unwanted situation hasn't changed, you can change the way you think and behave in a positive way. The therapy may have a role in the case of chronic low back pain for which no specific physical cause is evident.

Your doctor may talk to you about the psychological and social issues surrounding your chronic pain, such as whether you have stress, anxiety or depression, how your family has responded, how the pain has affected your work and other activities, and what you believe causes the pain to continue. You and your doctor may also talk about your readiness to accept that the condition will improve over time without any major medical intervention. Cognitive behavior therapy has been shown to be effective in relieving pain and improving function as one component of back care.

Multidisciplinary treatment programs.

A multidisciplinary approach to treating chronic low back pain involves, as the phrase suggests, a variety of therapies. These may include a combination of exercise, physical therapy, education, cognitive behavior therapy, vocational counseling and other strategies. Reviews of studies show long-term effectiveness of multidisciplinary treatment programs in lowering pain, improving function and reducing return to work time.

By Mayo Clinic Staff
May 13, 2008

H. Spinal Fusion

If the cause of your back pain seems to be motion between segments of your vertebrae, spinal fusion may be a way to prevent motion and stop the pain. Spinal fusion involves permanently connecting — or "welding" — two or more vertebrae together.

Spinal fusion was formerly used primarily for conditions such as scoliosis and other spinal deformities. Today, although most people with chronic low back pain don't need to undergo spinal fusion, it has become increasingly popular for treating low back pain. The number of spinal fusions for all causes in the United States has more than doubled since 1993. Spinal fusion has been used as a treatment for what's called discogenic pain — pain originating in the area of a particular disk and without involving leg pain (sciatica).

Evaluating your suitability

Before you and your doctor agree to surgery as an option, your doctor will want to make sure that you've given nonsurgical treatments a reasonable trial. Also, your doctor may conduct a study called a diskogram, which is a special X-ray examination that involves the use of a dye. The dye, injected into a disk, serves to make it appear better on an X-ray. The injection of dye may also produce a pain similar to your ongoing back pain, which helps your doctor pinpoint that disk as the source of your pain.

What to expect during the procedure

Spinal fusion surgery requires general anesthesia. The procedure may take from two to 12 hours, depending on how extensive the surgery is and the technique your surgeon uses. Surgery may involve a large incision, or may be done using newer techniques with smaller incisions.

To fuse the spine, your doctor needs small pieces of extra bone to fill the space between two vertebrae. This bone may come from your own body (autogenous bone), usually from a pelvic bone. Or, it may come from another person (allograft bone) by way of a bone bank. If the front of your spine is fused, the disk is removed first. Bone graft substitutes, such as genetically engineered proteins, are being developed as alternatives to using bones from your body or a bone bank. Sometimes, doctors also use wires, rods, screws, metal cages or plates. As with any surgery, spinal fusion carries risks, including pain at the donor site for the bone, infection and nerve injury.

The aftermath of surgery



Expect to be in the hospital for several days after surgery. You'll also likely experience considerable pain and discomfort after surgery, but your doctor will control pain with oral and intravenous medications. It takes from several weeks to several months to heal from this surgery, depending on your age, condition and what level of activity you plan to return to. The type of healing that needs to occur after spinal fusion is comparable to recovery from a broken bone. The earliest that X-rays might reveal bone healing after spinal fusion is about six weeks.

Spinal fusion removes some spinal flexibility. This can be beneficial if movement and instability between spinal segments is what causes your pain. However, the fused spine needs to be kept in proper alignment. You'll be taught how to move, sit, stand and walk in a manner that keeps your spine properly aligned. You may be able to start a physical rehabilitation program as early as about four weeks after spinal fusion surgery.

Set realistic expectations

Beyond the immediate potential risks of spinal fusion surgery, the areas of your spine adjacent to the fusion will bear more stress. This makes those areas more likely to experience future wear and tear. That may mean you'll need to undergo surgery again. About 20 percent of people who have spinal fusion surgery need another operation within 11 years.

Also, like any treatment for back pain, don't expect spinal fusion to eliminate your pain — just to improve it. For example, if your level of pain on a scale of 0 to 10 was a 7 before surgery, your doctor might regard a reduction to a pain level of 3 or 4 to be a successful result.

More study is needed regarding the long-term efficacy of spinal fusion to treat discogenic pain. A study published in the May 2005 issue of the British Medical Journal concluded that people who are candidates for spinal fusion may obtain benefits similar to those of surgery from an intensive rehabilitation program. A 2007 systematic review of several studies, including the 2005 British Medical Journal study, stated it wasn't possible to reach a definitive conclusion about whether fusion surgery might be effective in treating discogenic pain. The review did state that the nature of nonsurgical treatment of back pain "may be critical" in determining whether it's a better approach than fusion.

A 2004 opinion article in the New England Journal of Medicine stated that "the emphasis of research efforts should shift from examining how to perform fusion to examining who should undergo fusion. The indications for this invasive and expensive procedure remain unclear despite its rapidly expanding use." A 2007 article in the New England Journal of Medicine addressed the issue of who needs back surgery, and concluded that for people with major disability or major spine trauma, surgery "may preserve life or function." However, "absent major neurologic deficits, patients with herniated disks, degenerative spondylolisthesis, or spinal stenosis do not need surgery, but the appropriate surgical procedures may provide valuable pain relief."

At the time you and your doctor discuss whether you're a good candidate for spinal fusion, he or she may mention a newer option — disk replacement therapy. The Food and Drug Administration approved this therapy in 2004. However, it's still too early to know the long-term outcome of disk replacement therapy.

By Mayo Clinic Staff
May 13, 2008

I. Chiropractic

Spinal manipulation: Osteopathic or chiropractic manipulation appears to be beneficial in people during the first month of symptoms. Several studies have been performed on this topic and have produced conflicting results. The use of manipulation for people with chronic back pain has been studied as well, also producing conflicting results. The effectiveness of this treatment remains unknown. Manipulation has not been found to benefit people with nerve root problems.

J. Acupunture

Current evidence does not support the use of acupuncture for the treatment of acute back pain. Scientifically valid studies are not available. Use of acupuncture remains controversial.

K. Transcutaneous electric nerve stimulation (TENS)

TENS provides pulses of electrical stimulation through surface electrodes. For acute back pain, there is no proven benefit. Two small studies produced inconclusive results, with a trend toward improvement with TENS. In chronic back pain, there is conflicting evidence regarding its ability to help relieve pain. One study showed a slight advantage at 1 week for TENS but no difference at 3 months and beyond. Other studies showed no benefit for TENS at any time. There is no known benefit for sciatica.