WHY DOES BACK PAIN OCCUR?

Our back comprises of many bones supported by muscles, ligaments and other tissues. It extends from the neck to the pelvis. Most adults at some time or the other experience back pain. The most important part of the back is spine which has many smaller bones called vertebrae. These vertebrae are packed one above the other to form a column- forming the spinal column, vertebral column or spine.

The bones in the spine not only provide support to the body but also hold and protect the spinal cord. The spinal cord transmits all electrical signals to from the brain to and from various body parts including the nerves in the legs, arms and other areas of the body. The spinal cord extends from the base of the brain to just below the rib cage. Small nerves enter and emerge from the spinal cord through spaces between the vertebrae.



The vertebrae are separated and cushioned by intervertebral discs or spinal discs. These disks are made up of a strong outer fibrous covering (annulus fibrosis) surrounded by a soft, jelly-like center (nucleus pulposus). The discs act as shock absorbers for the vertebrae and save them from wearing undue wear and tear.

The flexibility inherent in the back especially in the neck makes it prone to various traumas like sprains and strains. The area of neck, shoulder and back is thus more susceptible to pain. Various causes could result in this pain and treatment options also vary accordingly.
Back pain can be of 2 types according to its severity:



  • Acute Pain
    It comes suddenly and the symptoms disappear within a few days or weeks. Most times it results from an injury or trauma or due to some other disease like arthritis. Its symptoms are muscle spasms and aches, shooting or stabbing pains, effecting mobility and motion of the body part and or causing difficulty in standing straight. It could even be caused by an injury to some other body part and many times without care deteriorates to serious chronic pain.
  • Chronic Back pain
    Longer lasting (more than 3 months) back pain and requires proper medical care. The pain keeps increasing gradually and the causes may be difficult to identify. Many times the pain may persist even after the underlying cause has been removed.



Back pain is caused by the main nerve centre and as such may radiate to other body areas also. This referred pain may be felt in:

  1. The shoulder.
  2. The neck.
  3. The head.
  4. The arms.
  5. The chest.
  6. The abdomen.
  7. The pelvis region.
  8. The legs.

Back pain in rare cases may be accompanied by scrotal or testicular pain and may be due to cancer in the scrotum/ testes.



WHAT CAUSES BACK PAIN?

Back provides support to the body and the spinal cord runs through it. As such many factors can affect this important area of the body. Back pain could be due to a muscle or ligament injury, nerve injury or deformity / displacement of the bone structure due to trauma or misuse. Back pain can be caused due to a multitude of factors.

Back pain is the second most common neurological ailment in the world and the only trouble more common than this is headache. Back pain is more common in the lower back, which bears more weight and stress than the rest of the back.

A bulging or ruptured inter vertebral disc may put pressure on one of the dozens of nerves rooted to the spinal canal that control body movements and transmit signals from various parts of the body to the brain. Irritated, compressed or pinched nerves can cause back pain. Developmental and aging related degeneration may also cause back pain. Back pain can also result from chronic disorders ranging from lupus to sickle cell anemia. However, in many other cases, the source of back pain can be difficult to determine. Many people develop back pain for no apparent reason.
Probable Causes of Back Pain
Back pain could result from many causes and at times it may be difficult the exact cause of this. Many factors are known to cause back pain or adversely affect existing problems and these could be:



Trauma / injury
Trauma or injury to the back caused by any reason – exercise, household activities, sudden movements, repetitive stress and sudden impact of an external force (accident, fracture or other such mishaps) may cause back pain. Sprain or injury to muscles or ligaments of the abdomen and the back (such as a sacroiliac sprain) may also be the reason.

An injury to the same spot again causes weakening of the original tissue because of the scar and this spot becomes prone to future traumas and even smaller injuries can cause pain.

Posture
Incorrect posture while walking, standing or sitting changes the body balance causing extra pressure on some muscles and joints bearing the full body weight due to this tilt. These muscles, over time, become vulnerable to stress and cause back pain. Sitting for long periods in one position can also be one of the causes.



Improper body movements
Sudden jerky movements, lifting weights by bending the back and not the knees while lifting weights and other movements causing stress on the back are a major cause of back pain.

Psychosomatic Stress
Individual experiencing stress due to various reasons resulting in emotional stress can have back pain and aggravate other medical conditions.

Obesity
Excessive weight of an obese person causes stress on the back muscles and other joints. This perpetual tension of these muscles in the back and abdominal region are overly stretched and become weak, reducing their capacity to support. This causes back pain in fat people.



Poor Fitness Levels
Obesity, lack of exercise and sedentary life style causes weakening of the body muscles and ligaments. This results in inadequate support to the spine making it vulnerable to al types of traumas / injuries / shocks.

Old Age
Old age causes certain body changes reducing bone density, bone strength and body and muscle elasticity. The inter-vertebral discs start losing their flexibility and internal fluid. The resultant loss of cushioning effect makes vertebrae more prone to injury and shocks. The chances of back pain increase with age after 30 years of age.



Heavy Back Packs / Brief Cases
Heavy back packs, brief cases and other luggage items tend to strain the back muscles, cause fatigue and injury. In children this can even cause permanent deformities.

An existing sickness can get aggravated to cause back pain. Some of these are:

  1. Herniated Discs
    A ruptured inter-vertebral disc can cause compression of the nerves and lead to back pain.
  • Sciatica
    Sciatica pain can also cause back pain.
  • Inter Vertebral Disc Degeneration
    As people grow old the discs in the vertebra lose their elasticity and impact on the nerve roots leading to basck pain.
  • Spinal Stenosis
    The spinal passage / canal gets narrowed due to various reasons causing pressure on the nerve roots and back pain.



  • Arthritis
    Each bone is joined to the other through the medium of a joint. Arthritis is deterioration of the joint causing pain within the joint. A facet or zygapophyseal joint connects the vertebras with each other. Various forms of Arthritis that causes back pain are:
  • Osteoarthritis
    It typically causes chronic degeneration of the cartilage of the joints. Spinal osteoarthritis is classified as spondylosis. Osteophytes or bone spurs may also be affected by this.



Rheumatoid Arthritis
It is diagnosed by the presence of RA Factor (Rheumatoid Arthritis Factor) in the blood. It is a chronic condition causing stiffness, weakness, loss of mobility, deformity and inflammation of the joints.

Ankylosing Spondylitis
It causes chronic inflammation of the spinal joints and ligaments.

  • Developmental Abnormalities of Spine
    The design of the spine is such that it places minimum strain on the body while providing maximum support. Any abnormality in this causes undue pressure and strain on the spine, vertebrae, supporting muscles, ligaments, tendons and tissues in the back causing back pain. These structural defects could be congenital or acquired:



Scoliosis
The spine has an abnormal sideways curve which causes strain on the spine itself.

Kyphosis
The spine has a prominent rounded forward curve in the upper back area and is also called “Dowager’s hump”.

Lordosis
Unlike kyphosis the abnormally prominent inward arch is in the lower back.

Osteoporosis
In old age women after menopause and even men suffer from unusual loss of bony tissue resulting in porous and brittle bones. It causes vertebral compression fracture causing posture abnormality and back pain.

  • Spondylolisis
    This is a condition of a stress fracture generally in the fifth lumbar vertebra in the posterior vertebral area (pars interarticularis). Mostly found in young athletes in school and people in any age group, it causes severe back pain. Spondylolisthesis is the condition in this when the affected vertebra gets severely weakened and slips out of place.
  • Enthesitis
    Arthritis or tendinitis causes inflammation of the specific sites (entheses) of attachment of ligaments or tendons to the bone. This condition called enthesitis causes back pain.



  • Polymyalgia Rheumatica
    It causes stiff muscles and pain in the neck, shoulders and pelvic region.
  • Fibromyalgia
    It causes tender spots/points on the neck, spine, shoulders and hips causing chronic pain in the muscles and tissues around these joints. It also induces fatigue and tenderness in the body at specific spots.
  • Chronic Fatigue
    This syndrome affects joints and muscles causing incapacitating pain in these..
  • Lupus
    Systemic lupus erythematosus is an auto immune disease affecting many body areas and can damage kidneys and body joints causing back pain.
  • Sickle Cell Anemia
    Genetic blood disease causing pain all over the body and also back pain.
  • Lyme Disease
    An infectious disease caused by ticks and causes joint and muscle pain all over the body.
  1. Neck Injury
    A sudden jerk of the head in an accident causes whiplash injury leading to neck and back pain.
  2. Temporomandibular Joint (TMJ) disorder
    This joint of the jaw when affected causes pain in the jaw (orofacial), headache, pain in the ear, neck, shoulder and back.
  3. Walking Styles
    Abnormality in the walking style or some gait disturbances cause or are caused by back pain.
  4. Paget’s Disease
    This disease causes enlargement and weakening of the bones resulting in fractures or even deformities.
  5. Disease of the Aorta
    Aorta, the large artery, directing blood from the heart to the body, develops a bulge or an aneurism and can sometimes cause back pain. Aneurisms in the thoracic or abdominal region are seldom symptomatic but a rupture in any aneurism is bound to cause sudden and severe pain in the back or abdominal region.
  6. Prostatitis
    This and other problems of the prostate can cause lead to back pain or pain in the pelvis or groin.
  7. Kidney Disease
    Kidney infection / disease (polycystic kidney disease) or kidney stones also cause back pain.
  8. Intestinal Disorders
    An infection or disease in the intestines or pancreas can be a cause for back pain.
  9. Diabetes Mellitus
    Diabetes and its related complications cause neuropathy and Diffuse Idiopathic Skeletal Hyperostosis (hardening of spinal and other ligaments). These diseases are known causes for back pain.



  • Cancer
    Cancerous growth in or near the spine impinges on the nerves and cause back pain. Metastasized cancer- cancer spreading from other body parts (prostate, breast etc) or pain from some forms of cancer like testicular cancer or even benign tumors can also cause back pain.
  • Porphyrias
    Congenital abnormalities adversely affect the production of heme- an important substance- that carries oxygen in the blood. The reduced production of heme causes acute porphyrias causing deprivation of the nerves of oxygen. The affected nerves cause pain in the back, chest and other areas.

Many times back pain is caused due to a muscular stress and gets better with rest and treatment at home with OTC medicines and /or heat, cold or water therapy. However, in case the pain does not subside within 72 hours, one should consult a physician for proper care, pain management and identification of the real cause.



WHEN SHOULD A PHYSICIAN BE CONSULTED FOR BACK PAIN?
Usually back pain not involving neurological symptoms will disappear without the need for medical care. Although it may take weeks for the pain to completely resolve, improvement should be evident within 72 hours.

Patients should consult a physician immediately if they are over 50 years of age, there is past history of back pain or cancer. A physician should also be consulted promptly if back pain:

  • Feels constant or intense, particularly at night
  • Spreads down one or both legs
  • Causes weakness, numbness or tingling in one or both legs
  • Causes new bowel or bladder problems
  • Is associated with abdominal pain or throbbing
  • Results from a fall or a blow to the back
  • Is associated with fever or unexplained weight loss
  • Does not improve when lying on one’s back



WHAT DIAGNOSTIC TESTS ARE REQUIRED FOR BACK PAIN?
Diagnosing back pain by a physician involves initial physical examination and past medical history to ascertain:

  • Location of the pain.
  • Extent of limit of range of motion due to pain.
  • Presence of muscle spasms, if any.
  • Assess muscle strength and any weakening.
  • Check patient’s ability to sit, stand, walk and lift both legs.
  • Check nerve reflexes with a rubber hammer.

The doctor will advise additional tests to identify a tumor, fracture, infection or other disease. These tests could be:

  • Pathological Tests
    Blood and urine samples are tested to detect various infections / diseases like arthritis to sickle cell anemia.
  • X-Ray
    An x-ray film may be taken to locate any fractures, degenerative bone disease or even bone density.ever, these images cannot reveal problems with the spinal cord, muscles, fibrous tissues, nerves or intervertebral discs.
  • Magnetic Resonance Imaging (MRI)
    Three dimensional or cross sectional images of the body parts/tissues are created by using sound waves and a magnetic field. These images are then used to examine the lumbar (spine) region for bone degeneration, diagnose injury or disease in tissues, nerves, muscles, ligaments and blood vessels.



  • Computed Axial Tomography (CAT Scan)
    In this test multiple x-ray images are taken from different angles and three-dimensional images of body structures are created. The test is used to locate disorders such as herniated discs, damage to the vertebrae or stenosis of the spine.
  • Ultrasound
    High frequency low energy sound waves are sent to the affected region against the internal organ or tissue. The waves that are not absorbed and bounce back are used to create images of the tissues. Any abnormality like kidney stones etc. is detected with the images thus formed.
  • Radionuclide Bone Scan
    A small amount of radioactive substance is injected into the patient’s veins and a special camera is used to identify any problems in the bones that are highlighted by the contrast medium. It helps in revealing bone tumors or compression fractures caused by osteoporosis or any other cause.



  • EMG (Electromyography)
    This test measures electrical impulses generated by nerves and the response generated in the muscles by these impulses. The muscular reaction helps identify any type of nerve compression resulting from herniated discs or spinal stenosis.
  • Inter-vertebral Discography
    The suspected disc suspected to cause back pain is examined by injecting a special contrast medium (dye). X-ray images taken thereafter reveal the highlighted damaged areas and the physician is able to decide the next line of treatment- surgery to remove the sequestrated disc or part thereof. Injecting an anesthetic with the dye in to the disc to conduct functional anesthetic discography is a variation of this test.
  • Lumbar Tapping
    Spinal tapping is carried out by extracting the cerebrospinal fluid through a needle from the spinal canal. The analysis of this fluid to identify central nervous system disorders, Lyme disease or tumors.
  • Facet Joint Injections
    Injections are sometimes given in to the facet joints to identify the cause of back pain. This is the “last resort test” when other tests have been proved inconclusive.



WHAT TRETMENTS CAN BE TRIED AT HOME FOR RELIEVING BACK PAIN?

Back pain is likely to be experienced by most people at sometime or the other in their lives. It can generally be treated at home and the symptoms disappear within 72 hours while total relief may occur in a few days. Some of these treatments are:

  • OTC Medicines
    Generally, non-steroid anti-inflammatory drugs (NSAID)to ease back pain are used for back pain. Aspirin or ibuprofen relieves inflammation, stiffness and any swelling. However, even OTC drugs have side effects in larger doses and a physician should be consulted before taking these medicines.
  • Hot and Cold Therapy
    Cold compresses (cryotherapy) on the affected area can soothe sore and inflamed muscles. Ice should not be applied directly but only after packing it in a cloth/towel. Hot compresses (thermotherapy) can be used after cold compresses after a gap of 2 days. Each application should last not more than 20 minutes at a time. These compresses can be used till symptoms last.
  • Heat treatment can be given by using a heat lamp or heating pad after 2-3 days of cold compresses. This helps in relieving tight muscles. There is no scientific proof for this treatment but invariably these provide relief from pain and help in improving mobility.
  • Physiotherapy / Physical Activity
    Taking up light activities helps but care needs to be taken to stop any movement in case of difficulty or muscle pain. A physiotherapist or a physician can advise about specific activities to gradually exercise the inflamed muscles. Bed rest for more than 2 days is counterproductive and gradually swimming, walking stretching etc. can be started.



WHAT TREATMENT SHOULD BE TAKEN FOR SEVERE BACK PAIN?
After trying home care also if the pain persists after 72 hours, professional medical care must be taken. The physician will prescribe NSAID’s and other medication to relieve muscular pain. A range of these drugs are available to help in mild to moderate back pain. These medicines could be given orally or applied on the skin as creams or sprayed. These medicines dull the pain sensation by providing stimulation to the nerve endings.

  • Additional Medication
    In addition to NSAID’s some other types of medicines given are:
    Analgesics & Anticonvulsants
    Seizures are treated with anticonvulsants but are also helpful in treating nerve pain. Used in combination these are often useful.
  • Antidepressants
    Tricyclic antidepressants in particular and even some other antidepressants can be used to relieve pain and help with sleep. The prescribing physician has to monitor the patient for any unusual behavior since use of these drugs may cause a tendency for suicide.
  • Mild Anesthetics
    Opium derivatives are prescribed for short periods of time under close supervision of a physician, to manage severe pain. The possible side effects of these are drowsiness, slower reaction time, impaired judgment, depression and addiction after prolonged use.



Other Treatments
In addition to medication some other treatments options include:

  • Bracing
    Spinal bracing is used to treat scoliosis to spinal cord injuries. The braces help in supporting the spine.
  • Nerve Stimulation
    Muscle spasms and back strain caused pain is treated by providing electric stimulation to the affected muscles. Sciatica may be relieved by using trans-cutaneous nerve stimulation under the supervision of a physician. The device for providing periodic stimulation can be surgically implanted in the affected area under the skin.
  • Physio-therapy And Exercise
    Massage therapy by experts may precede deep heating ultra-sound therapy (iontophoresis) to relieve back pain. Even electric impulses can be used to deliver medicines through the skin. After sufficient improvement is mad an exercise regimen can be planned to meet the specific requirement. The emphasis will be on strengthening exercises for back and abdominal muscles (improve support for the spine), posture correction and improve flexibility with adequate instructions on body mechanics to prevent recurrence of injury.
  • Occupational Therapy
    In chronic cases the patient is guided to adapt and independently perform daily routine activities of self care and household.
  • Stress and Behavior management
    Management of stress and behavior modification of the patient is carried out. Replacing negative thoughts with positive ones help the patients with chronic pain.



Alternative Treatment
Patients may try alternative treatment options like:

  • Acupressure and Acupuncture
    As per this therapy the body has certain trigger points, for each body part/activity, located at specific points. Manipulation of these points by exerting pressure or use of needles helps in relieving pain and in stimulating the part to perform better. Acupressure involves applying pressure on the trigger points to effect improvement. In acupuncture needles the width of a human hair are inserted into trigger points around the body. These systems work on the principle of release of natural painkilling molecules in the body with the treatment. These molecules relieve pain and tissue inflammation. Care needs to be maintained in proper sterilization of the needles to avoid spread of infections.
  • Biofeedback
    The patient is made aware of the muscular tension, heart rate ans body/skin temperature. A special electronic machine devised for this purpose helps the patient in understanding and controlling these body actions to overcome pain through relaxation techniques aimed at changing their response to pain.
  • Spinal / Nerve Stimulation
    Local anesthetics or corticosteroids are injected in to joints, nerve roots or soft tissues affected by pain. Nerve and spinal stimulation techniques are also applied to relieve back pain.
  • Traction
    Readjustment of bones/vertebrae is attempted by providing traction with the use of weights to align the displaced bones. The counter force helps in relieving the pressure existing on the bones resulting in relief from the symptoms. Traction is applied along with medicines.



Spinal Surgery
In cases where all other treatments have failed and the patient is suffering from consistent severe pain due to undue compression on the nerves; surgery may be the other option to relieve back pain. The type of spine surgery may be:

  • Laminectomy or Laminotomy
    (spinal decompression). Due to degenerative changes or trauma a vertebra might have been misaligned causing back pain. The lamina (arched roof of the spinal canal) of one or more vertebrae is removed. In this process the bone spurs of the vertebra or fragments impinging on the nerves roots in the spinal canal are removed. By increasing the size of the spinal canal, this procedure may reduce pain by helping alleviate spinal cord and nerve pressure. It may be used for spinal stenosis. Partial removal of a lamina is known as laminotomy.
  • Disectomy
    This procedure is used to remove all or part of an intervertebral disc and is one of the more common ways to relieve pain and nerve pressure in the back or neck caused by a sequestrated disc or bone spur. Percutaneous discectomy is an improved variation using a thin tube inserted through a smaller incision and is effective in relieving some cases of disc herniation and relieves sciatica.
  • Spinal Fusion
    This vertebral fusion procedure is most useful to strengthen spinal function while preventing painful movements. The process involves removing two or more spinal discs from between the vertebrae. The effected vertebrae are then fused together by using bone grafts or metallic devices like screws etc. the fusion is carried out to improve degenerative changes caused by osteoarthritis, rheumatoid arthritis, spinal stenosis, herniated discs and other degenerative disc diseases. The procedure is helpful in removing painful movement but takes longer time for recovery.



  • Vertebroplasty
    Vertebrae damaged due to fractures caused due to degenerative changes caused by osteoporosis are repaired by injecting bonding agent like cement in to the affected vertebrae. Another version of the procedure is Kyphoplasty.
  • Inter-Vertebral Disc Replacement
    The affected disc is removed and a synthetic (artificial) disc is inserted in its place.
  • Device Implantaion
    Cases where other treatment options are either not available or can not be used, a small pump like device is installed under the skin in the back. This pump like device releases pain medication at specified intervals to relieve the back pain.



WHAT STEPS CAN I TAKE TO PREVENT FURTHER INJURIES OR NEW INJURIES?

The spine is supported by muscles of the back and abdomen as these serve as a natural corset for the back. Any steps undertaken to strengthen these muscles are helpful in preventing spinal injury and risk of back pain. Even adopting correct posture especially while sitting and standing is useful.

Exercise schedules developed with the help of a physiotherapist help increase strength and flexibility. The gradual increase of exercise regimen is essential to avoid injury more so for people who have suffered a back injury already, in the past. The exercise pattern used must include:

  • Strength and Flexibility Improvement
    Weight training, Yoga, tai-chi and other exercises schedules help in strengthening abdominal and back muscles. These also improve flexibility in the joints, hips and upper legs essential for proper pelvic bone alignment and movement.
  • Aerobic Exercises
    Regular aerobic exercises increase strength and endurance of the lower back. Walking, swimming or cycling are effective and do not cause strain or jolt to the back.
  • BMI Control
    Body Mass Index is a good indicator of proper body weight. Excess weight causes avoidable stress and strain on the back.
  • Stopping Smoking
    Inhalation of tobacco smoke causes a major drop in the level of oxygen supplied to the body, especially the spinal tissue. Lack of oxygen slows down the natural repair process of the damaged muscles and tissues after a sprain or trauma.
  • Exercising caution
    It is necessary to take adequate care during daily routine activities to avoid spinal injury and resultant trauma pain. Using proper seat belts, care while lifting heavy baggage and avoiding any action likely to put undue strain on the back muscles, will help in preventing back pain.



  • Well Balanced Diet
    Taking proper diet that provides all required vitamins like vitamin D, calcium and magnesium etc is necessary. It will help in reducing risk of osteoporosis and resultant fractures. Oranges, yellow vegetables and fruits are rich source of carotenoids. Broccoli and cabbage provide essential enzymes that help in preventing arthritis and protect the joints. Seafood and meat are also known to help in preventing osteoarthritis.

Lifting heavy weights properly and proper posture can help eradicate chances of injury to a large extent. Learning to adopt these small changes in posture and ergonomics in daily routine is necessary:

  • Using Knees-Not Back
    This simple adaptation can reduce the chances of injury in most cases. When lifting heavy objects, keep the back straight and the load close to the body. Do not twist the back while lifting. Bending from the waist to pick up even lightweight objects from the floor can strain the back. For lifting a heavy or awkward load seek someone’s help.



  • Adopting Proper Posture
    People who are required to stand for long periods of time should relieve the pressure from the back by placing alternate foot on a small footstool. While standing it is necessary to keep the pelvis in a natural position. Using a chair with proper back support, arm rests and a swivel base for sitting is useful. Support the small of the back to maintain its normal curve by using a rolled up towel or a small pillow. Adjust the heigt of the chair to keep the knees and hips level.
  • Selection of Mattress
    Sleeping on a semi firm mattress is good as compared to a very firm / hard one. Using an old, sagging bed or mattress causes back pain. Height of pillows must match the shoulder width only. A pillow that is very high or too low can force the neck in a severe angle and result in neck and back pain.

Patients required to be administered long term medicines like corticosteroid therapy may have to be given bisphosphonates to lessen the chances of osteoporosis and vertebral fractures

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