BACK PAIN

BASICS

COMMON QUESTIONS,
UNCOMPLICATED ANSWERS
About the North American Spine Society

The North American Spine Society (NASS) is the world’s

largest multidisciplinary organization that advances quality
spine care through education, research and advocacy.
NASS members are MDs, DOs and PhDs in 22 spine-related
specialties including orthopedics, neurosurgery, physiatry,
pain management and other disciplines. Nurse practitioners,
physician assistants, chiropractors, physical therapists,
practice administrators and other allied health care
professionals involved in spine care also are represented.

Why is a multidisciplinary approach to back pain

so important?

Research shows that by combining a variety of treatment

options to address an ongoing back pain problem, patients
often have more positive results than with just one treatment
method alone. A multidisciplinary approach may include
treatment such as physical therapy, pain management (for
example, medications, spinal injections and coping strategies),
body mechanics/ergonomics and various forms of exercise
including complimentary approaches like Pilates or yoga.

Sometimes back pain will resolve itself with one form of

treatment, but not always. With a multidisciplinary treatment
program, a patient may take advantage of multiple forms of
treatment simultaneously with better results. The goal is to
find the right combination of treatments to alleviate back
pain, and most importantly—improve overall quality of life.

Finding the right treatment plan for you is the first step in
managing your back pain. For more information on spine
care or to find a spine specialist in your area, please go to
www.spine.org or call (866) 960-NASS.
BACK PAIN BASICS
COMMON QUESTIONS,
UNCOMPLICATED ANSWERS
Back pain is no laughing matter. In fact,
nearly everyone in their lifetime will suffer
with some type of back pain. Because
back and neck pain are such common
complaints, it’s no surprise that people
have a lot of unanswered questions on the
topic. This booklet briefly addresses some
of the most commonly asked questions
NASS members receive about back pain,
its treatment and prevention.

1
 So…what exactly causes back pain?

Oh, my aching back! We’ve all said it at some point in our

lives. As painful as it can be, the exact source of back pain
is often difficult to identify or pinpoint. In fact, there are
numerous possible pain producers including muscles, soft
connective tissue, ligaments, joint capsules, cartilage, discs
and nerves. Through everyday activities—exercise, lifting,
playing a sport, etc.—these areas may be pulled, strained,
stretched or sprained. Sometimes, small tears that occur in
the outer layer of a spinal disc can result in severe pain. Many
people experience pain from an abnormal disc that may be
degenerating, bulging or even herniated. Even if the actual
tissue damage is considered minor—and likely to repair on
its own—the intensity of the pain might be quite severe.

There is often a chain reaction which contributes to a person’s

pain experience. In the body, numerous chemical substances
are released in response to tissue irritation or injury. These
substances “stimulate” the surrounding pain-sensitive nerve
fibers, resulting in the sensation of pain. Some of these
chemicals trigger the process of inflammation, or swelling,
which also contributes to pain. The chemicals associated
with this inflammatory process feed back more signals which
perpetuate the process of swelling. The inflammation from
this cycle of events may persist for days to weeks.

2
How long does an episode of back pain
typically last?
No matter how long it lasts, back pain isn’t fun when it’s
happening to you or someone you love. Unfortunately, the
duration and severity of a single episode cannot be predicted
based on the onset, location of pain, or even the initial
severity. There are three general categories of pain—acute,
chronic and recurrent acute.

The good news is that even if the exact source of pain is not
determined, usually acute pain subsides over a month or less
as the back’s irritated tissue heals. In general, nearly 80% of
first time low back pain episodes resolve by six weeks.

Chronic pain is generally described as pain that lasts for

months at a time and is often less correlated to tissue
damage or injury and may be the result of a more long-term
spine condition or other related factors such
as muscle weakness, body weight, and certain
life stressors.

Recurrent acute pain is intermittent—

it comes and goes or “flares up”
from time to time.

3
 What is the best pain relief medication for
back pain?
A third of Americans rely on over-the-counter medications
like acetaminophen and nonsteroidal anti-inflammatory
drugs or analgesic pain relievers to reduce swelling and
aches associated with back pain. These types of medications
prove to be very effective in reducing symptoms and
providing comfort.

The NASS “Back Pain in America” survey found that one in

five people rely on prescription medications under the care
of their doctor to treat their back pain. Despite the name,
muscle relaxants are medications that don’t actually relax
skeletal muscle. What these drugs do is calm or sedate the
central nervous system and can be also useful to facilitate
sleep and reduce contributing emotional or muscular tension
associated with severe back pain.
Narcotics or opioids are strong
pain relievers and help reduce
the symptoms of acute back
pain. Because these types of
drugs are sedatives,
they also can be
useful in facilitating
sleep during the first
few nights after the
symptoms first occur.
These medications
should be used only
as prescribed by a
physician.

4
When I’m experiencing back pain, should I lay flat
and rest my back?
Actually, some of the best advice for treatment of acute back
pain is to get out of bed and remain as active as tolerated.
Continuing to perform everyday activities may seem
counterproductive, and the natural inclination may be to stay
on the sofa and avoid activity. Yet, activity may be exactly what
you need to keep blood and nutrients flowing to the affected
area, inhibiting inflammation and reducing muscle tension.

Many people who suffer from back pain find that they can
perform their usual, but more controlled cardiovascular
activities—such as walking—in spite of the pain, and
often feel better as a result. More vigorous or uncontrolled
activities such as weight lifting, competitive or contact sports
are not recommended when the pain is severe. Consult with
your physician before returning to these types of activities.

5
 Should I ice or heat a sore low back?

This is probably one of the most commonly asked questions

about treatment of back pain. Both ice and heat can help in
alleviating pain, but it’s important to know when to use them.

Ice reduces inflammation or swelling by decreasing blood

flow from constricted blood vessels. Placing an ice pack on
the area shortly after the pain begins (within 48 hours) can
help with pain relief. Apply an ice pack to the affected area
for up to 20 minutes every two hours, but remember to
protect your skin from frostbite by using a thin sheet
or towel.

Local application of heat or ice can temporarily reduce back

pain and heat may facilitate stretching. Heat also is good for
soothing sore back muscles, especially after the initial 48
hours has passed. Either dry heat (such as an electric heating
pad) or moist heat (such as a hot bath or steamed towels) can
be used.

It is important to keep in mind,

however, that ice and heat do
not necessarily speed long-
term recovery.

6
Does my weight matter much in relation to my
back pain?
Your personal fitness will contribute to the overall health of
your spine and weight control is an important component to
maintaining a healthy back. Keeping on additional weight,
especially in the mid-section or stomach, shifts your entire
center of gravity forward and puts additional unneeded
strain on your back muscles
and surrounding tissues.
We recommend keeping
within 10 lbs. of your ideal
weight to avoid experiencing
unnecessary back pain or
related issues.

However, it is also possible to

be too thin. Extreme thinness
can be accompanied by low
bone mass, putting you at
risk for osteoporosis. The best
advice is to eat a well-balanced
diet in moderate quantities and
exercise regularly to keep your
weight in check.

7
 What is the best type of exercise to alleviate and
prevent back pain?
Exercise is one of the most important treatments that your
doctor will recommend to reduce back pain. Regular
strengthening (core strengthening and resistance or weight
training), flexibility (stretching) and aerobic exercise (three
to five times per week) will improve your overall fitness and
reduce further likelihood of back injury.

Many doctors and specialists provide their patients with

proper exercise techniques to alleviate symptoms and
prevent further back pain episodes from occurring. When
exercising, follow these simple rules:

• Do each exercise slowly.

• Start with five repetitions of each exercise, and work up to
10 repetitions.
• Always remember to begin and end your exercise sessions
with stretching.

8
Does my sleeping position and mattress choice
matter in avoiding back pain?
Many people don’t realize that sleeping on your back puts 55
lbs. of pressure on your spine—but simply placing a couple
of pillows under your knees cuts the pressure in half. Lying on
your side with a pillow between your knees also reduces the
pressure on your low back.

There are a wide variety of choices today when it comes

to selecting a mattress. Mattresses and box springs work
together to provide support for your body while you sleep.
You can find mattresses with varying levels of firmness,
innerspring options, etc. There is not a single type of mattress
that works for everyone. We recommend trying several in
the store before making a purchase—many companies offer
a trial period so you can sleep on a new mattress for up to a
month to ensure you’re comfortable and pain free.

9
 What is the proper posture to avoid injuring
my back?
As a child, you probably heard a parent or teacher tell you to
“stand up straight!” Simple as it sounds, maintaining proper
posture is an important way to keep the many intricate
structures in the back and spine healthy and help reduce the
incidence and levels of back and neck pain. Not maintaining
good posture and adequate back support can add strain to
muscles and put stress on the spine. Over time, the stress
of poor posture can change the anatomical characteristics
of the spine, leading to the possibility of constricted blood
vessels and nerves, as well as problems with muscles, discs
and joints. All of these can be major contributors to back and
neck pain.

Follow these simple guidelines to avoid injuring your back

while performing these common activities:

Standing—Keeping one foot forward,

with knees slightly bent, takes
pressure off your low back.

Sitting—Sitting with your

hips slightly higher than
your knees reduces low
back strain.

Reaching—Stand on a
stool to reach things
that are above your
shoulder level.

10
What are the proper ways to move heavy objects
and lifting techniques to avoid injuring my back?
Lifting and bending are often major culprits when it comes
to the onset of back pain. Using proper lifting and bending
techniques will help reduce stress on the lower spine and
help eliminate injuries. Follow these tips:

Use your legs—When bending and lifting, make sure to bend
your knees so that your legs help distribute the weight more
evenly. Squat with your chest sticking out forward and your
buttocks protruding out backward. This position keeps your
lower back in a neutral, safer position.

Keep the weight close—When you lift and carry a heavy

object, keep the weight as close to your body as possible.

Balance your load—Two smaller

objects (one in either hand) may
be easier to carry than one large
one and also reduces the stress on
one side of the body.

Avoid twisting—A surefire way

to harm your back is by twisting
when lifting an object because
it puts too much pressure on the
structures of the lower back.

Push instead of pull—Pushing is

much easier on your back than
pulling. Use your arms and legs to
start the push. If you must move a
heavy item, don’t do it alone—get
someone to help you.

11
 If I have chronic back pain, would it be better to
have surgery?
There is no simple answer to this question. Treatments for
chronic back pain will vary depending on the type and
source of the back pain. If a treatable source of the pain is
found, then the underlying process can be addressed. When
the underlying cause is either not specifically identifiable or
not amenable to treatment, then the symptoms are treated.
The goals of the treatment are to reduce pain, improve
quality of life and increase function.

There are several different

general categories of treatment
recommended for chronic back
pain. They include physical
therapy, medications, coping
skills, procedures and alternative
medicine treatments. Your
treating physician should
tailor a program involving a
combination of these options to
address your needs.

Actually, 90% of the care NASS

members provide is non-
surgical. We have found that
only 1% of back pain sufferers
need surgery.

12
How do I choose a specialist to treat my back pain
and which type of specialist is best?
A NASS survey revealed that more than half of the responders
with back pain turned to a back or spine specialist such as
a chiropractor, physical therapist, physiatrist, orthopedic
surgeon or neurosurgeon for treatment. Your primary care
physician should be helpful in pointing you to the most
relevant specialist for your back pain. Each care plan is then
tailored to the individuals’ specific medical needs.

For more information on spine care or to find a spine

specialist in your area, visit www.spine.org or call
(866) 960-NASS.

13
 Consumer resources from the North American
Spine Society
For additional information on back pain, conditions and
treatments, go to www.spine.org.
Test Your Back Knowledge
• Know Your Back! • Seven Back Pain Warning Signs
• Back Quiz for Women • Back Pain Risk Scale
Prevention and Spine Health Maintenance
• Ten Tips for a Healthy Back • Exercises for a Healthy Back
• Back Pain in Pregnancy • Strength Training for the Elderly
Specific Spine Conditions and Treatments
• Bone Graft Alternatives • Open Discectomy
• Cervical Spinal Stenosis • Osteoporosis
• Discography • Postprocedural Discitis
• Electrodiagnostic Testing • Radiographic Assessment
• Herniated Cervical Disc for Back Pain
• Herniated Lumbar Disc • Spinal Fusion
• Lumbar Spinal Stenosis • Spinal Injections
• Lumbar Zygapophysial • Spondylolisthesis
(Facet) Joint Injections • Stingers
• Magnetic Resonance • Treatment of Young Athletes
Imaging (MRI) • Whiplash & Whiplash Associated
• NSAIDS Disorders
New Technologies
• Artificial Discs
• Bone Morphogenetic Protein
• Intradiscal Electrothermal Therapy (IDET)
• Percutaneous Vertebral Augmentation
Patient Safety
• Patient Safety: Tips to Help You Safeguard Your Health
• AHRQ Patient Fact Sheet: Five Steps to Safer Health Care
• AHRQ Patient Tip Sheet: How to Protect Yourself and Your Family
from Medical Errors!
14
About the Contributing Editors

Marjorie Eskay-Auerbach, M.D., J.D. is currently in private practice in

Tucson, AZ. Dr. Eskay-Auerbach is a member of the North American
Spine Society’s Board of Directors, co-chair of the NASS Socioeconomic
Affairs Council and also serves on the NASS Professional Conduct
Committee.

Heidi Prather, D.O. is currently an associate professor and chief of

section for Physical Medicine and Rehabilitation in the department
of Orthopaedic Surgery at Washington University Medical School
in St. Louis, MO. Dr. Prather is the co-founder and director of the
Musculoskeletal Fellowship in Physical Medicine and Rehabilitation at
Washington University and involved in medical student and resident
teaching. Her clinical interests include the conservative management
of all musculoskeletal conditions with a special interest in women’s
health and performing arts. She serves in national leadership roles as
a board member of the North American Spine Society and National
Association of Spine Specialists, and is the current President of the
Physiatric Association of Spine Sports and Occupational Medicine.

Stuart M. Weinstein, M.D. is a board certified physiatrist (a specialist

in Physical Medicine and Rehabilitation). Dr. Weinstein is currently
a full-time clinical faculty member at the University of Washington
in Seattle, WA, and holds the rank of professor in the Department of
Rehabilitation Medicine with joint appointments in the Departments
of Orthopaedic Surgery and Sports Medicine, and Neurological
Surgery. His medical practice primarily focuses on the management of
spinal and other musculoskeletal conditions without surgery, with a
particular interest in spinal problems in athletes and exercise therapies
for back pain. He is an active member of the North American Spine
Society and is currently a member of the Board of Directors.

© 2007, North American Spine Society

Published by:
North American Spine Society
7075 Veterans Blvd.
Burr Ridge, IL 60527
(866) 960-NASS
www.spine.org