Health & Wellness

Oh, My Back!

Low-back pain is common, but it’s also manageable

By Wendy Haaf

Photo: iStock/BakiBG.

If you’re standing in a crowd, the odds are that at least one of the people on either side of you has experienced at least one episode of low-back pain, and if everyone present is 55 or older, that number may be even higher; studies suggest that prevalence increases with age until about 65. Yet, for a number of reasons, including persistent, widespread misconceptions among the general public and health professionals alike, low-back pain “is often poorly managed,” says Raja Rampersaud, a spine surgeon, a professor in the Department of Surgery at the University of Toronto, and the provincial clinical lead for low- back pain with Health Quality Ontario. We spoke to three experts to get the facts on managing and preventing back pain.

In most cases, the cause is not serious.
“The vast majority of back pain, roughly 95 per cent, is non-specific, or mechanical,” explains Brenna Bath, an associate professor in the School of Rehabilitation Science at the University of Saskatchewan’s College of Medicine in Saskatoon. This means there’s a problem with the way the muscles and joints are working together. Even in the roughly five per cent of people who have back pain that shoots down the buttocks, back-related leg numbness, tingling, or weakness in the leg—which indicates that a nerve exiting the spinal column is being squeezed or irritated—the nerve is not being damaged.

However, there are times when back pain warrants urgent investigation: when it’s accompanied by red-flag symptoms such as loss of bladder or bowel control, unintentional weight loss, a throbbing sensation in the abdomen, and progressive weakness or numbness in the legs. Imaging may also be recommended when pain occurs after a fall to rule out vertebral fracture due to osteoporosis.

Imaging is nearly always unhelpful—and in fact, can actually lead to harm.
In non-specific low-back pain, X-rays and MRIs don’t provide any useful information. “Everyone over the age of 20 will start to have degenerative changes in the spine,” Bath explains, but these are not a reliable predictor of pain. In fact, “in a few studies, in which researchers have taken people off the street who don’t have back pain and done MRIs, nine out of 10 showed some degeneration,” she adds. And imaging won’t change the approach to treatment.

So there’s no benefit, and the potential harm isn’t limited to unnecessary exposure to radiation from x-rays. Some people interpret findings showing degenerative changes as evidence of a more serious problem. “That in itself can feed into an increase in pain,” Bath says, since worry and anxiety amplify physical discomfort. People who think this way may also begin to restrict their activities and to rest for long periods, which can actually prolong pain and boost the chances it will recur or become chronic.

“What we know from the evidence, and even from how the muscles and joints work, is that outcomes are better for people who stay active and keep moving,” explains Catherine Trask, the Canada Research Chair in Ergonomics and Musculoskeletal Health and an associate professor with the Canadian Centre for Health and Safety in Agriculture at the University of Saskatchewan in Saskatoon. Inactivity leads to a loss of strength and coordination in the muscles that support the back, as well as a loss of flexibility and mobility in the joints—all of which can exert extra stress on the spine and cause more pain.

By contrast, activities that strengthen the “corset” of muscles that support the spine and help them work in a coordinated manner have the opposite effect. Functional training, which prepares the body for everyday activities such as hefting a bag of groceries, is one example.

“Being moderately physically active, whether that be walking, swimming, biking, or other activities, can mitigate or reduce the onset of back pain, or at least minimize the impact of it when it’s there,” Trask says. “Exercise is the only thing that’s been shown to help people long-term,” Rampersaud stresses. Consequently, the goal of any treatment—from anti-inflammatories and heat to massage or manipulation—is to help you stay active and do exercises that are appropriate for your back. For example, for someone with back-related leg weakness or pain, riding a stationary bike or swimming might be good options, Bath says.

When it comes to treatments and exercise, one size does not fit all.
“Unfortunately, patients can get varying opinions and treatments that make the problem worse, not better,” Rampersaud says. “If you’re not improving within two weeks, and certainly if you’re getting worse, then that’s the wrong treatment, and your provider should be changing it or reassessing it.” Providers who press you to continue along the same path are banking on the fact that most back pain will improve within a month or two, no matter what you do. “It shouldn’t be a codependent relationship; you should be able to learn to manage your back pain on your own,” Rampersaud emphasizes.

“Not one treatment has been shown to be better than all others for all things; it needs to be individualized,” he adds. Similarly, what constitutes exercise appropriate for your back “is going to vary from person to person,” he says. “You want to move your back, not to the point where you’re torturing yourself, but in a progressive, sensible way, finding different types of movement that actually make it feel better and don’t aggravate it.” Some lifelong exercisers can do this on their own, but many people need help building a program. “A health-care professional such as a physiotherapist, who is a movement specialist, can assess someone and provide advice, both on specific exercises someone can do at home and the types of activities that might be beneficial for overall fitness and health,” Bath says. (For evidence-based information on low-back pain management, see the “Resources” sidebar on page 17.)

While most acute low-back pain will resolve in roughly six weeks, that doesn’t necessarily mean it’s
gone forever.
In a study Rampersaud co-authored, which looked at a group of more than 12,000 Canadians who filled out community health surveys over a 16-year period, “only one in five people with back pain reported it once and never again,” he says. “Another one in five reported it every year. Another third reported it coming on more and more frequently, and in another third, it came and went.” However, getting the right advice and support early on can potentially reduce the odds of such recurrences and give people the tools they need to manage any future flare-ups.

Even back pain that radiates down the leg often doesn’t require surgery.
The two most common causes of back pain that radiates down the leg are disk herniation and spinal stenosis. In the former, one of the squashy cushions between two vertebrae bulges out and presses on the nerve root (which sits between the disk and the bone) or even breaks open, leaking material that can trigger the release of compounds that inflame the nerve. The result? Pain—often fiery—shooting down the buttock and thigh.

“In 80 per cent of those folks, it will settle,” Rampersaud says; this involves a combination of medication (usually a non-steroidal anti-inflammatory) and movements that don’t increase the pain. “Taking something for pain is definitely something to consider early,” he adds. For some people whose pain doesn’t begin to improve after six weeks of this approach, an injection into the spine (by a specialist) can bring relief. However, “in 10 to 20 per cent of people, the pain persists long enough that surgery [to remove a portion of the disk] becomes an option,” Rampersaud says. In most studies, roughly 90 per cent of people who have this procedure report relief from leg pain. Depending on how tolerable the symptoms are, “you shouldn’t wait forever” for a referral, he adds, because “if the pain is going to start improving, it tends to do so within the first six weeks to three months, and after that, it gets less and less predictable.”

In spinal stenosis, which becomes increasingly prevalent after age 50, an arthritis-related accumulation of extra bone narrows the space around the spinal cord and the openings where nerves exit the spine; the resulting tighter quarters put pressure on the nerve. Typically, someone with spinal stenosis will begin to experience leg numbness, tingling, weakness, or even pain travelling down the leg after walking a certain distance. For some people, “short-duration manual treatment and specific exercises to help open up the structures can help manage it, and people may be able to tolerate walking a little more,” Bath says.

If such measures don’t help, how-ever, surgery—in this case, to remove the extra bone that’s compressing the nerve—is possible for a much wider range of patients than would have once been offered such an operation. Now, because of advances in surgical techniques, such an operation is often a possibility even for elderly people.

“In most people, we can do a small microsurgical day procedure, where the risk of something bad happening is extremely low,” Rampersaud says. Yet, “there’s still a lot of fear and ageism when it comes to spinal surgery, and many people suffer with something that’s actually very fixable.”

The procedure is on par with knee replacement for improving quality of life; however, because depositing of extra bone continues, 20 to 30 per cent of people will experience a recurrence within five to 10 years.

You can take steps to reduce your chances of experiencing back pain.
Since we’re designed to move, “staying still is not great for our bodies,” the University of Saskatchewan’s Catherine Trask says. Prolonged sitting—especially if you’re also bent over looking at a work surface, even if your posture is ideal—is a risk factor for back pain, so limiting sedentary time and taking regular movement breaks are worthwhile goals. And surprisingly, making sure your eyeglass prescription is up-to-date may also help. “If we haven’t been for an eye checkup in a while, we use the ‘manual zoom’ function—leaning closer to anything that requires a good visual connection with what we’re doing,” Trask explains. “Often, visual demands lead to a more hunched-over posture.

“The best inoculation against serious back pain is to keep active and keep moving,” Trask says. That doesn’t necessarily mean hitting the gym or even participating in low-impact sports such as cross-country skiing to achieve an overall active lifestyle; you can build more opportunities for movement into your day, such as raking leaves rather than using a blower or walking instead of driving when doing a few errands. Regardless of which approach you choose, Trask says, “it’s never too late to do healthy things for your back.”