BACK PAIN

At one time or another, 8 out of 10 Canadians will experience back pain. In fact, pain in the middle or lower back is the leading cause of disability in people under the age of 45.

When back pain strikes, it can range from a mild, persistent ache to unbearable pain with the slightest movement. While there are many causes of back pain, most episodes are associated with inflammation of the soft tissues surrounding the spine.

HOW COMMON IS BACK PAIN?

Every year, at least one-and-a-half million Canadians seek medical help for back pain—much of which could have been avoided. (See Back Pain Prevention, Risk Factors and Wellness Tips.) Low back pain is second only to the common cold as a cause of lost workdays.

WHAT CAUSES BACK PAIN?

Most cases of back pain result from weakness of the back muscles caused by living a sedentary lifestyle. This includes the back pain associated with stress, when the back muscles often go into spasm. Spasm also occurs if you have been doing something strenuous like gardening, or move suddenly after holding an awkward position. It is particularly common following a twisting motion, when many cases of a “pulled back” occur.

The intervertebral disks—which act as shock absorbers— are subjected to different types of stress during the process of everyday living. While this stress may not result in pain at the time the injury actually occurs, the repeated injuries add up. Bending over results in compression of the disk, and can cause it to bulge backwards towards the spinal canal and nerves. Twisting and bending together produces the greatest stress on intervertebral disks. Degeneration of the disks can give rise to chronic back pain as the muscles supporting the disks go into spasm. The degenerating disk can itself become inflamed and may cause mechanical pain.

The lower part of the back (the lumbar region) is the most vulnerable area of the back. This is largely due to the fact the lower part of the spine bears the entire weight of the upper body and is bent, twisted and flexed during everyday activities more than any other part of the spine.

The actual pain associated with damage to the supportive soft tissues (muscles, tendons and ligaments), and the intervertebral disks themselves, is caused by the inflammatory process.

WHAT CAUSES INFLAMMATION?

Inflammation is the body’s natural response to being injured. It is characterized by redness, swelling, heat and pain. When your soft tissues become inflamed, you may experience any or all of these symptoms.

TREATMENT FOR BACK PAIN

Treatment for back pain usually involves strengthening the back through special exercises and adjusting the lifestyle to avoid the stressors (physical and mental) that have contributed towards the injury. (See Back Pain Prevention, Risk Factors and Wellness Tips.) In the case of persistent, debilitating pain, prescription or over-the-counter analgesics (painkillers) and muscle relaxants may be used. Surgery is considered a last resort for continuing, debilitating back pain.

PHYSICAL MANIPULATION TECHNIQUES

Physical manipulation via qualified healthcare professionals (chiropractors, osteopaths, physiotherapists, massage therapists and others) has been shown to improve quality of life in many people suffering from back pain. Non-invasive manipulation techniques and the excercise and stretching protocols these healthcare professionals recommend can be very helpful.

MEDICATIONS

Although medications will not cure back pain of degenerative origin, medications are routinely used to control pain, inflammation, muscle spasm, and associated disruption of sleep. There are two categories of back pain medications: those that relieve the symptoms, and those that may help modify the disease process itself.

MEDICATIONS THAT CONTROL SYMPTOMS:

ACETAMINOPHEN
Acetaminophen (Tylenol®, Panadol®, Exdol®, and others) is often prescribed to relieve mild to moderate back pain. Acetaminophen is not an anti-inflammatory drug and may therefore usually be safely combined with an anti-inflammatory medication to relieve pain. (Please consult your doctor or other health care practitioner regarding medications that are appropriate for you.)

While acetaminophen can bring relief for back pain, it does not help the underlying cause of the condition. Overdosing can cause liver damage. (If you are taking acetaminophen on a regular basis to control pain, you should make sure that other over-the-counter medications such as cold and flu remedies do not contain enough acetaminophen to constitute an overdose.)

NSAIDs
Pronounced “ensayds,” these drugs help reduce pain and swelling while decreasing stiffness. NSAIDs that require a prescription include Naproxen®, Relafen®, Indocid®, Voltaren®, Feldene® and Clinoril®. Other NSAIDs are available over-the-counter. These include ASA (Aspirin®, Anacin® and others), and ibuprofen (Motrin IB®, Advil® and others.) When a low dose is taken, NSAIDs control pain, but higher doses are required to reduce inflammation. The problem with NSAIDs is their side effects. Taking more than one NSAID at a time increases the possibility of heartburn and severe side effects such as ulcers and bleeding. NSAIDs inhibit the blood’s ability to clot properly and may therefore interact with blood-thinning medications such as coumadin.

Cox-2 Inhibitors
This sub-class of NSAID has recently been introduced to the North American marketplace. The most frequently prescribed Cox-2 inhibitors are celecoxib (Celebrex®) and rofecoxib (Vioxx®). Unlike standard NSAIDs, Cox-2 inhibitors do not inhibit proper blood clotting. Recent evidence, however, strongly suggests that Cox-2 inhibitors have the same degree of negative side effects as standard NSAIDs—including contributing to kidney failure—and may increase the risk of heart attack and other cardiovascular problems.

*Important News Release September 2004
Vioxx®, the cox-2 inhibitor made by Merck, has been pulled from the market because of severe lethal side effects due to heart attack and stroke.

MUSCLE RELAXANTS

Muscle relaxants that address back pain are available as prescription and over-the-counter medications. Over-the-counter muscle relaxant medications include Robaxin® (methocarbamol), Robaxacet® (methocarbamol and acetaminophen) and Robaxisal® (methocarbamol and ASA). Prescription medications include Soma® (carisoprodol), Flexeril® (cyclobenzaprine) and Valium® (diazepam). Soma is typically prescribed on a short-term basis and may be habit-forming, particularly if used with alcohol or other drugs that affect the mind. Flexeril may be used on a longer term basis. This drug may impair mental and physical function and can lead to urinary retention in men with enlarged prostates.

Valium is usually restricted to one to two weeks of use. Due to this drug’s habit-forming potential, and its propensity to alter the sleep cycle, it is not prescribed for the long-term. Since valium is a depressant, it can worsen the depression often associated with chronic pain.

MEDICATIONS THAT MAY HELP MODIFY THE DISEASE PROCESS

Nutricol®, available as Recovery® in many pharmacies and health retailers, is a food-based non-drug supplement proposed to improve quality of life*.

Nutricol® (Recovery®) may be safely combined with other back pain medications or taken on its own to help improve quality of life*. It does not produce unpleasant side effects. Since this product works to modify your body’s responses, it may take up to six weeks for you to experience relief, with most people noticing benefits within a month.

View feedback from health professionals and users of Recovery® with Nutricol®.

EPIDURAL STEROID INJECTIONS

When analgesic drugs don’t work, doctors may suggest an epidural steroid injection (ESI). This procedure involves placing a small amount of cortisone into the spinal canal. Cortisone is a powerful anti-inflammatory drug that may help to bring the inflammation surrounding the nerves under control. Unfortunately, ESIs have a success rate of only 40 – 50 percent.

SURGERY

Surgery is usually a last-resort solution for back pain. Each surgery is unique to the patient’s specific symptoms and there is no procedure that “fits all.” Common surgical procedures include diskectomy, complete laminectomy and spinal fusion.

Diskectomy is the removal of a herniated disk to relieve pressure on a nerve root; laminectomy is the removal of the lamina (the back portion of the spine that forms the roof of the spinal canal) to allow more room for nerves, and spinal fusion involves placement of a bone graft between two or more vertebrae, which causes them to grow together, stopping the motion between the vertebra caused by segmental instability.