Lower Your Risk For Back Pain With Prevention
The concept of prevention does not have a great track record, and this dismal situation is true not only for back pain but for most health issues. It’s really quite simple. Healthy people lack motivation to participate in preventive activities. They wait until they have their back attack (or other illness) and then try to prevent a recurrence.
Once you have had one back attack, you are at greater risk of having another within a year. Some studies suggest this is true for as many as 50 percent of back pain sufferers. However, the second attack is usually milder than the first. The second attack occurs because people forget the lessons learned from the first back pain episode. They go back to their old habits and lift objects from awkward positions, stretch too far, or sit too long.
Do not become a repeat back offender. Remember what caused your first back attack. Practice good body mechanics, rest when appropriate, and exercise at the correct time of the day (generally later in the day). If you follow these simple rules, a second attack of pain is less likely. Here are my guidelines for avoiding back problems—and preventing them from recurring.
If you are a smoker, make every effort to stop now—your back, along with your lungs and heart and other organs, too, will thank you. All the tissues of the body require oxygen to maintain their function, and smoking robs these tissues—especially your spinal discs—of the optimal amount of oxygen. Because no blood vessels supply the interior of the discs, all the oxygen has to seep in from the surface. If the blood contains less oxygen, the discs receive less, too, and lack of oxygen is part of the disc disintegration process that increases the risk of herniation.
When you are physically fit you are at less risk for developing low back pain. We can define fitness in a number of ways. For example, cardiovascular fitness is the ability to climb stairs or run without getting short of breath. In a study of fire fighters, those in good physical condition had significantly decreased risk of back pain compared to those in poor physical condition.
Strong back muscles represent another type of fitness. Compared to other muscles in the body, the muscles in the back are generally weak; if we increase strength in these muscles, we can decrease our risk of developing low back pain. While this is important for everyone, it is essential for those whose jobs require heavy lifting and physical labor. Exercises that strengthen the muscles in the front (abdominal flexors) and in the back (back extensors) can decrease your risk of injury if you lift heavy objects or twist and bend frequently while at work.
Do your general fitness exercises every other day. The day off allows your body to revitalize muscles fatigued by the exercise. Engage in an exercise program vigorous enough to stimulate about thirty minutes of perspiration. “Breaking a sweat” means you have used enough calories to generate heat, which is a sympathetic nervous system response that benefits the part of the nervous system that inhibits pain. These types of exercise also improve circulation, flexibility, and muscle tone.
Maintain a Good Body Weight
Obesity in itself is not a risk factor for the development of low back pain, but it prevents you from doing exercises properly and comfortably. If obesity results in a sedentary lifestyle, then all the risks associated with inactivity remain present. For most people, the body mass index (BMI) is a good measure for whether or not you are overweight. For example, if you are six feet tall and weigh 200 pounds, your BMI would be 27, which is a bit high. You would do better at a weight of 170 or 180. If you are five-foot-five and weigh 150 pounds, you would have a BMI of 25. Guidelines from the National Institutes of Health define overweight as a BMI greater than 25. Obesity starts at a BMI of 30.
Use Good Body Mechanics
The spine is a beautifully engineered structure, and we know posture is good if someone can effortlessly maintain normal position and movement for extended periods of time. Maintaining normal posture is a function of the ligaments that support the spine and legs and also of normal tension in muscles. When any component of the balanced spine is moved off center, this effortless state is altered (fig 11.1).
Every day, your spine enables you to accomplish a number of tasks without pain. Think of it. Your spine supports your body when you lift a large object, and it stays straight when you make it sit in a car on a drive from Washington, D.C., to Boston, with only one stop for gasoline. If your spine is positioned correctly while you accomplish these tasks, you will suffer no ill effects. However, if a heavy load is off center, which twists your back, or if the car seat offers no support, you will probably develop back pain.
When lifting any object, your feet and your back should be going in the same direction. You should face the object, bend your hips and knees, and lift with your legs, not your back. The object should be kept as close to your body as possible. If you can, it is better to lift the object from a height as opposed to lifting it from the ground.
If you must lift heavy objects frequently, consider using an abdominal corset to increase intra-abdominal pressure to support your spine. These corsets are not magic—they don’t work if they aren’t closed around your body. At one of the local hospitals, I noted that many of the hospital employees leave the corsets open. A recent study showed that most people who are given instructions about using abdominal corsets still use them incorrectly. However, the corsets may be helpful, even if left open, if it makes you remember to lift with your legs, not your back.
Standing in one position for a length of time can lead to fatigued muscles in your lower back. You may have experienced this feeling at a party where no chairs are available, or in a museum with no place to sit down. The upright posture increases the curve in the lumbar spine and stretches the muscle (psoas) in the front of the spine that travels to the hip. Lift one leg to rest on a stool. Transfer weight from foot to foot, or flatten your back with a pelvic tilt (see chapter 8). These positions take pressure off the psoas muscles and the curve of your back. Do these with any activity that requires prolonged standing, such as ironing, giving a lecture, or painting a wall.
A good sitting posture requires that the height of the seat allows your feet to be flat on the floor, with your knees at slightly above 90 degrees. The back of the chair should support the lumbar curve. Chairs used in offices have an adjustable back and wheels, and the tension and position of the back support should be adjustable along with the height of the seat.
If you are experiencing back pain, the best chair for you has a firm upholstered seat, with a firm straight back and armrests. Wait to use the soft, sofa-type chair when your back pain has totally resolved. In a soft chair, your back is constantly making adjustments to support your spine, and these tiny adjustments can cause fatigue or increase pain because your back is working very hard. When you sit in a chair with firm support, the muscles can relax because the chair supports them.
Many of us get into trouble when we stretch. You’re the last one on the plane, so you have to stretch to squeeze your carry-on bag into the overhead bin between suitcases that seem to weigh a ton. Or you have to stretch across the bed to tuck a sheet under the corner. Maybe a bag of groceries has shifted to the farthest recesses of your car trunk. In these situations, you may stretch to reach, only to recognize that you are about a foot too short for the task! About five seconds later, the muscles in your low back and side have realized this fact, too, and now they are in spasm.
The simple answer to overstretching is to get closer to the object you want to move. If it is above your head, get a step stool. (If it’s in an overhead airline bin, ask for help.) If you must reach the other corner of the bed, put one knee on the mattress and move closer to the corner. Instead of bending over to vacuum, kneel down on your knee to keep your back straight, depending on the type of vacuum you have, of course. Place packages in the front of the trunk, or on the backseat of the car.
Avoid Back Fatigue
Never stay in one position for an extended period of time. Whether you’re standing or sitting, change the position and move around at least once an hour, more frequently if your back quickly fatigues. Constant contraction of muscles makes them fatigue, and once that happens, they start to ache. Aching muscles are weaker muscles, and once their functioning is compromised, you are at greater risk for injury.
It’s easy to forget simple prevention tips. For example, you may sit like a prisoner on an airplane. But take a stroll to the lavatory even if you don’t need it. If you sit at a computer, remind yourself to get up to get your muscles moving. If you spend hours on the phone for your job, get a headset if possible, which allows you to get up and walk around. All these activities improve the function of your lumbar spine, and it will thank you by aching less.
When back pain is related to your job, it is often complicated by the interaction with your employer and the workers’ compensation system. And if you were unhappy with your work environment, that could prolong your back pain as well as your return to work. You need to be compensated fairly for loss of working time, and you also need to modify the conditions at your job that caused the back attack in the first place, whether you have a desk job or one that is physically strenuous. It’s important to return to work, in any capacity, early in the course of a back attack. The longer you are out of work, the less likely it is that you will ever return to gainful employment. If someone is out of work for one year after a back injury, the chances of returning to a job are essentially zero. Max, a forty-five year-old office worker came to my office three days after the onset of pain associated with a lifting accident at his work. His office was moving to another location in the building, and he had been lifting boxes for two days. He developed pain and stiffness in his back that made it impossible for him to sit at his desk. He had muscle strain associated with lifting (he had twisted his back frequently). He was treated with medications and a five-day sick slip. When he returned to my office, his back pain had improved and his muscle spasm resolved. He was sent back to work with the recommendation that he be excused from any additional lifting associated with his office move. He was encouraged to move frequently during the day. With the modification in his work duties for three weeks, Max had total resolution of his back pain and has returned to his usual job.
The therapies in my basic back pain relief program can help you if you were injured at work. Once you are pain free for five to ten days, returning to work is feasible. Don’t carry objects greater than ten pounds initially, even if your job involves heavy lifting. Always use good body mechanics—your feet and face are in line, with no spinal twisting. As you feel more comfortable with lighter lifting tasks, you can progress to lifting heavier objects. If you sit for most of the day, remember that sitting puts strain on the lumbar spine. Get up frequently to relieve back muscle fatigue.
Keep Your Bones Strong
Starting at an early age, our goal should be to prevent osteoporosis before our bones reach that stage when they weaken and become thin. This means maximizing our bone calcium during adolescence; maintaining bone calcium during adulthood; and for women, minimizing postmenopausal bone loss. Bone calcium increases in children and adolescents who consume higher levels of calcium in food or supplements. However, high calcium intake during the postmenopausal period has no effect—or a minimal protective effect—against bone loss in women. (Men also get osteoporosis, but in smaller numbers.)
To maintain bone strength, most adults should have 1000 to 1500 mg of calcium per day. In addition, regular weight-bearing exercise, like walking, contributes to the development of bone mass, and resistance or impact exercise, such as lifting weights, helps maintain bone mineral levels.
In Caucasian women, calcium intake should be 800 mg a day until age ten, then 1,500 mg during adolescence and pregnancy, and 1,200 mg during adulthood. Vitamin D, 400 to 800 IU, is a valuable supplement used in conjunction with calcium supplements. This is particularly helpful for the elderly who have limited exposure to sunlight, or nutritional deficiency. The combination of these supplements decreases the risk of hip fractures in elderly populations. Non-Caucasian women start with a greater amount of bone mineral calcium. They should take calcium supplements, but they are at less risk for fractures.
Hormone Replacement Therapy for Women
The reason osteoporosis is considered a women’s health issue is because estrogen deficiency after menopause leads to bone loss. The greatest rate of bone loss occurs in the first years after cessation of ovarian function. Estrogen replacement therapy, commonly called ERT, is often started soon after the onset of menopause in women who are appropriate candidates. Some women begin hormonal therapy during the perimenopausal periods. ERT is not recommended if you have a history of breast or uterine cancer or clotting disorders. To prevent bone loss with ERT, women need estrogen every day. For women with an intact uterus, progesterone is added because it decreases the risk of uterine cancer. This combination therapy is called HRT, hormone replacement therapy. The Women’s Health Initiative, a large, national study of women taking estrogen and progesterone replacement therapy, reported an increase in cardiovascular disease and breast cancer in the group taking HRT. The study was stopped prematurely because of the concerns regarding the ill effects of HRT. The appropriate role of HRT remains very much in question. The use of HRT is a personal choice that must be discussed with your physician.
Raloxifene (Evista) is a selective estrogen-receptor modulator (SERM) with estrogen like effects on bone resorption but without stimulating breast tissue or the lining of the uterus in postmenopausal women. Raloxifene, given in daily doses, effectively increases bone and decreases the risk of spine and hip fracture. Toxic side effects include hot flashes, leg cramps, and rare episodes of venous clotting.
Calcitonin is a hormone that reduces bone breakdown and is used to treat osteoporosis, and salmon calcitonin is more effective than human calcitonin. Calcitonin is given by injection, or intranasally, on a daily basis. Nasal calcitonin decreases the risk of spinal fractures but may not significantly alter the risk of hip fractures. However, one of the added benefits of calcitonin is its pain-relieving effects, particularly on bone fractures.
Bisphosphonates came into medical use in a roundabout way, and their concept is based on research that studied detergents and hard water. Bisphosphonates attach to bone crystals, the sites of active bone remodeling. Bones are living tissues, constantly being built up and torn down, and bisphosphonates alter bone remodeling by reducing the tearing down portion of remodeling. By decreasing bone resorption, bone density is increased.
Alendronate (Fosamax) effectively prevents and treats osteoporosis because alendronate is a potent inhibiting agent of bone remodeling. Studies of women with established osteoporosis have found that alendronate given every day prevents postmenopausal bone loss and increases bone density in the spine by approximately 4 to 6 percent over a three year period. Alendronate also has a beneficial effect on increasing bone density in the hip. A smaller daily dose of alendronate is comparable to ERT in preventing bone loss. The effect on bone is prolonged, meaning that it’s measured in years; therefore, younger women of childbearing years are not candidates for this agent. Alendronate comes in a larger-dose pill that allows administration once a week with the same beneficial effects as the daily dose. The larger dose formulation is more convenient than the smaller daily dose. This weekly regimen decreases exposure of the esophagus and, hence, reduces irritation.
Risedronate (Actonel) decreases the risk of spine and hip fractures as well as increasing bone in these locations. This drug has been recently approved by the FDA for the treatment of postmenopausal osteoporosis at a single daily dose. Actonel, a once-weekly pill has also been approved.
The primary toxicity of the bisphosphonates is gastrointestinal, and they tend to have poor intestinal absorption. These drugs must be taken on an empty stomach. For example, alendronate should be taken in the morning after an overnight fast, with a large glass of water. In addition, you should remain upright for thirty minutes to assure that the medication remains out of the esophagus, because heartburn is a common complaint.
Get Plenty of Antioxidants in Your Diet
Make sure your diet contains abundant amounts of fruits and vegetables, which are good sources of vitamins A, C, and E, the antioxidants. Beta-carotene is found in green and yellow fruits and vegetables like cantaloupe, apricots, spinach, and carrots. Dairy products and eggs provide vitamin A, citrus fruits are loaded with vitamin C, vegetable oils supply vitamin E.
Scientific evidence proving the direct benefit of antioxidants on intervertebral discs is still lacking. Although I do not have the clinical trials to prove it, I believe that antioxidant supplements have the potential to slow oxidative damage to the spine. Discs of the spine are one of the places that might benefit from this therapy. An adequate dose of antioxidants, preferably from food, is important to maintain spine health.
Our exposure to free radicals is part of the ongoing aging process throughout the body, including the spinal discs. In an autopsy study of people aged thirteen to eighty-six, oxidative damage was identified in cartilage cells in the middle of the discs. The damage started in the teenage years and continued in each age group. In addition, evidence of the body’s attempts to repair the oxidative damage was present in all examined discs. This study confirmed the notion that disc degeneration from oxidative damage starts in the second decade of life.
These active oxygen molecules (free radicals) attach to cells in your spinal discs and cause damage. The cells try to repair the injuries but are ineffective, which means the disc wears out too soon. Antioxidants (vitamins E, A, C, and beta-carotene) are able to neutralize the damaging effects of oxygen radicals.
If you take these nutrients as supplements, keep in mind that the fat-soluble vitamins A and E are absorbed and stored with fat and thus are eliminated very slowly. Excessive amounts can accumulate in the body and become toxic. Health problems associated with taking these antioxidant supplements at levels above the recommended limits include kidney stones and diarrhea with vitamin C, increased bleeding in people taking anticoagulant medicines with vitamin E, and hair and nail breakage with selenium. Doses of vitamin A at a level of 100,000 units are toxic. The National Academy of Sciences has recently set “upper intake levels” for vitamins C and E and the mineral selenium as follows: