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It's pretty basic: Before you can find effective, safe, long-lasting relief for your chronic back pain, it helps to know why you hurt. Once you have a handle on the cause of your pain, you can begin to review and implement the various approaches described in this book to help alleviate it. I also believe that you should have some knowledge of how to recognize the different conditions that may be causing your back pain and, more important, how to explain your pain and any accompanying symptoms. In this way, you can help your health-care practitioner arrive at a more accurate diagnosis. Also, I find that patients are more likely to stick with and follow a treatment program if they understand what they are treating and why. So let's get started with a few basics and then move on to the causes of your pain.
I introduce quite a few terms in this chapter and in the next one and a few illustrations to help you understand them better. Although it isn't critical for you to fully comprehend each of these terms, I believe it's important that you are at least familiar with them, as they are words your doctors and physical therapists may use when they talk about your condition. And while theworkings of the human body can seem truly amazing at times, I don't believe patients should be kept in the dark or mystified by what is happening to them, especially when they are in pain.
ACUTE VS. CHRONIC BACK PAIN
Acute or chronic? Acute pain is typically defined as pain that lasts less than three months, while a label of chronic indicates pain that lasts longer. In most cases, acute back pain is the result of a bodily injury, such as a muscle strain, that heals within a month or two. Often, however, chronic back pain begins as acute back pain that becomes persistent: there may be an acute physical injury that may be the result of an automobile accident or something as simple as straining a muscle while bending to pick up a pencil that has fallen onto the floor. Some patients who come to see me don't remember doing anything that triggered the pain. "It seemed to come out of nowhere," some tell me, or "It seems like I've been living with this back pain for so long, I can't even remember when it first started."
Symptoms of chronic low back pain vary. The pain may be stabbing, piercing, shooting, or throbbing; it may be localized or referred from another part of your body; it may occur only when you sit, stand, walk, or turn. Along with the chronic back pain, you may have other symptoms, such as fever, headache, tingling or pins and needles in your legs, muscle weakness, or weight loss-any one or more of which suggest you may have an infection or another medical condition that may be causing or contributing to your pain and should prompt you to seek immediate medical attention. One common symptom I see in patients who have chronic low back pain is depression, which is three to four times as prevalent in such patients as in the general population.
The Pain Paradox
A paradox about low back pain is that the severity of a person's physical condition does not necessarily translate into a similar level of pain. Some people, for example, have herniated discs, yet experience absolutely no pain, while other individuals can have a simple muscle sprain and become incapacitated. For some people, the pain flares up at irregular intervals, with weeks, months, and even years between episodes. Each episode can differ in severity, duration, and how it responds to treatment.
The important thing to remember is that all of these symptoms, and any I have not listed, as well as patterns of painful episodes are important to share with your health-care practitioner. Every bit of information is a piece of the puzzle, clues to the cause of your pain. Ultimately, they can help your physician determine the type of treatment options that will work best for you.
LOWER BACK BASICS
The spine is composed of up to thirty-three interlocking bones called vertebrae that are stacked in an S-shaped curve arrangement. This arrangement allows the spine to absorb the stress that body movement places on it, as well as helps it support the body's weight. These functions of the spine are not shared equally by the three regions that make up this structure, however (see figure 1.1). The vertebrae in the lower, or lumbar, region are thicker and sturdier than those above it, and for good reason: unlike the cervical and thoracic regions above it, the lumbar region performs the critical task of acting as a cushion for the weight of the upper body.
The bottom of the lumbar region ends at the sacrum, a bone that consists of five vertebrae that are fused together. The sacrum, together with the pelvic bones, forms the pelvic girdle, a critical structure when it comes to the functioning of the spine, because it balances the spine and connects it with the legs.
The lumbar region is composed of a complicated infrastructure of nerves, muscles, tendons, ligaments, veins and arteries, vertebrae, and spongy cartilage tissue. While all of these structures contribute to the complexity of the lower back, the nerve supply is especially intricate, because much of it overlaps as it makes its way to the different muscles, ligaments, tendons, discs, and other tissues in the spine and legs. In fact, this overlap can make it very difficult for the brain to distinguish between an injury to, say, a disc versus a tendon.
For example, a herniated disc can feel just like an injured ligament or a bruised muscle, but it's important to differentiate them because they should be treated differently. Therefore, it's important for your physician to conduct a thorough medical history and physical examination, as well as get a detailed account from you about your symptoms. This is why I urge you to take notes-literally write down the information in a pocket-size notebook if you need to-about what you feel, when you feel it, and how long it lasts. Such input is key to the diagnostic process, which we will discuss in the next chapter.
If you get nothing else from this chapter, it's important to understand this about back pain and your muscles: If you want to win against chronic low back pain, you must keep your muscles healthy. The back consists of dozens of different muscles, and all of them work together, either directly or indirectly, and are connected to nearly every major muscle group in the body. Thus, when any muscle within this interconnected structure is stressed, tense, or in spasm, it can impact the function and health of many others throughout the body as well. Therefore, keeping your back muscles healthy is good for more than just your back; it benefits your entire body.
The significance of this connection is even more relevant once you know that muscle pain from a strain in your back is generally ten to twenty times more painful than a muscle strain that occurs anywhere else in the body. That's because most of the pain receptors in your back are in the muscles. Most people don't realize this fact, so when they experience back pain, they automatically think, "I must have a ruptured disc" or "I have a pinched nerve," when in most cases their muscles are causing the pain. And the pain does not have to feel like an ache; it can also be stabbing, piercing, burning, or throbbing.
That being said, let's take a quick look at some of the main muscles involved in keeping the lower back healthy. It may seem like I'm overwhelming you with a lot of terms, but I think it's important for you to have at least a casual knowledge of these muscles so you can get a better appreciation of the complexities of chronic low back pain. Plus, you may recognize some of the terms your health-care practitioners use when they talk to you.
First, let's talk about the muscles that support the spine. Extensors are a group of muscles that straighten the back as well as lift, extend, and move the thighs away from the body. Among this group is the largest muscle in the body-the gluteus maximus in your buttocks-which stabilizes the hips. It also attaches to the lumbodorsal fascia (a fascia is a fibrous, strong tissue that covers and/or separates muscles into groups), a structure that stabilizes the lumbar spine and pelvis and also works in conjunction with other pelvic and leg muscles. If your gluteus maximus is weak, you likely stand with your pelvis tilted one way or another, which places excessive stress on your hip capsules and lumbopelvic ligaments and allows your muscles to weaken. A weak gluteus maximus also permits more stress to be placed on your spinal discs and facets, which causes your lumbosacral joint (where the bottom of the lumbar spine, L5, meets the sacrum) to break down prematurely and contributes to low back pain. Another contributing factor is weak lower extremities. The weaker your leg muscles, the greater your tendency to depend on and eventually wear down your lumbar spine.
Another muscle group is the flexors-the abdominal and psoas muscles-which help bend and support the spine from the front of the body. They also flex and move the thigh in toward the body and influence the arch of the lower spine. Weak abdominal muscles are an invitation for lower back problems. When abdominal muscles are toned and strengthened, back pain often is reduced. (We'll talk much more about this in chapter 3.) The psoas muscles, which connect the bones of the upper thighs to the spine, support and stabilize the spinal column. Some people who experience severe back strain also report having pain on both sides of the groin. This pain may be caused by spasm of the psoas muscles, which react this way in an attempt to stabilize the spinal column.
The third group is the obliques, or rotator muscles (side muscles). These flat muscles stabilize the spine when you are upright, help stabilize and support the lower back and pelvis, rotate the spine and maintain correct posture and spinal curvature, and share some of the weight load with the discs, thus protecting them from injury.
Let's not forget the hamstring muscles, which are located in the back of the thigh. These muscles connect to the bottom of the pelvic bone, which connects to the base of the spine. If your hamstring muscles are tight-which is very common in people who sit a lot-a domino effect can occur: Tight hamstring muscles place stress on the pelvic bone, which pulls on the spine and transfers the weight of the spine onto the discs. This creates instability in the spine and can lead to muscle spasms and tension on the spine. This is why it's important to stand up and stretch your hamstring muscles at least every few hours whenever you sit for a prolonged period. Hamstring muscles can also become tight from poor posture, especially swayback, which is characterized by an increase in the natural inward curve of the lower back.
If you have pain in your buttocks that travels down your leg, you may be feeling your piriformis muscle, which is located deep in the buttocks. If this muscle becomes constricted or spasms, it can irritate the sciatic nerve and cause the characteristic buttocks and back-of-the-leg pain associated with sciatica. We'll talk more about sciatica later.
Before we leave the muscles, I need to mention a few more structures that you'll read about in the next chapter: the tensor fascia lata and the iliotibial band. The tensor fascia lata is a short muscle, and the iliotibial band is fascia. As a unit, these structures run the length of the outer thigh. Individually, the tensor fascia lata flexes and internally rotates the hips, while both structures work together to help stabilize the leg while standing and are often involved, either directly or indirectly, with low back pain.
Perhaps the most talked about parts of the back are the discs or, more accurately, the intervertebral discs. These structures are formed from cartilaginous tissue and are sandwiched between and cushion each of the vertebrae, which prevents them from grinding against each other. The discs perform a critical role, as they help absorb shocks to the spinal column that are placed on it during everyday activities. In addition to handling the weight of the upper body, the lumbar region also must support the weight of whatever you pick up or carry, and your waist acts like the fulcrum, or pivoting point, in a lever system when you lift.
For example, if you lift a 10-pound bag of dog food, you place approximately 100 pounds of pressure on your lower back and increase the pressure inside your lumbar discs. This is a significant burden for your lumbar spine to bear. Intervertebral discs are designed to transmit and distribute that pressure evenly and thus allow normal activities to continue while preventing injuries. One reason discs are able to do this is their high water content makes them very elastic, which helps make and keep the spine flexible. For the first thirty or so years of life, the gel in the inner part of the disc (the nucleus pulposus) is composed of approximately 90 percent water. This percentage gradually decreases over the next forty years or so to about 65 percent. As the percentage decreases and the discs lose their thickness, the space between the facet joints also decreases. The overall result is a loss of disc height (and the related loss in skeletal height; we shrink as we age), reduced ability of the discs to absorb shock, and reduced flexibility, all reasons why the backs of older adults are less nimble than those of younger people.
Another thing you'll hear quite a bit about is facet joints. Facet joints are paired, thumbnail-size joints located on the back of the spine, where they help stabilize the lower back and guide its motion. Each vertebra has an upper and lower facet that link together to form a joint. In some individuals, these joints become painful and stiff. We'll talk more about facet joint pain and how it can be diagnosed and treated in chapter 6.
All together, the structures of the lumbar region help to regulate the functions and impact the health of the abdominal and pelvic organs and muscles, as well as the bones and joints of the legs. Thus, the lower back is very vulnerable to stress, strain, sprains, and other injuries that may come its way, and the result of such injuries is often inflammation and pain.
The spinal ligaments have been likened to very tough rubber bands in that they are strong, elastic, and fibrous. These essential qualities allow them to perform their job, which is to help support the vertebrae and protect the spinal column from injury.
CAUSES OF LOW BACK PAIN
Lots of words get bandied about when people talk about low back pain, words that can be pretty scary. "Slipped disc," "bulging disc," "herniated disc," and "degenerative disc" are popular, as are phrases like "arthritis of the spine" and "scoliosis," or "curvature of the spine." And many people believe that these or other physical defects or weaknesses are the cause of their back pain. Fortunately, it's often just not true. (See Delia's Story below.)
The truth is, the majority of low back pain-about 97 percent-is caused by stress, trauma, or injury to the spine's muscles, ligaments, facets, or sacroiliac (SI) joint (more on these structures below). Most chronic low back pain is muscle related. Of that 97 percent, more than 70 percent is associated with muscle-related factors, such as strains, muscle tension and inflammation in the lumbar region, myofascial pain syndrome, and fibromyalgia, with degenerative disc or facet disease coming in a distant second (an estimated 10 percent). The remaining mechanical causes of low back pain are divided among various other physical conditions, which total about 14 percent. The remaining 3 percent is divided among diseases that affect different organ systems (about 2 percent) and nonmechanical spinal conditions (about 1 percent). (See the Causes of Low Back Pain table.)
Excerpted from What Your Doctor May Not Tell You About Back Pain by Deborah Mitchell Debra K. Weiner Copyright © 2007 by Debra K. Weiner, M.D., and Lynn Sonberg. Excerpted by permission.
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