Causes of

Back Pain

As I've already said, most back pain is caused by lifestyle and aging. There are, of course, many other causes, including disease and injury. Back pain caused by overexertiona form of injuryis also very common. About 60 percent of industrial back injuries result from overexertion, usually in the form of strains or sprains. Emotional stress can also bring on tension, which in turn tightens muscles and cause discomfort. Then, too, there are those cases where you and the healthcare professionals just can't determine exactly where the pain comes from . . .

I know what your thinking. But, Dr. Chiu, you said that there is hope for all back-pain sufferers. Well, the statement in the last paragraph doesn't change anything. Even those cases where we can't determine exactly what the problem isand those are becoming rarecan be helped through a proper back-care program.

If you were to ask me to tell you what causes back pain in one sentence, after a little thought, I'd say: "Back pain causes include: poor posture, lack of exercise, obesity, trauma and

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back strain, ruptured or slipped disc, wear and tear, arthritis or osteoarthritis, degenerative disc disease, tension and emotional problems, and sometimes we aren't so sure."

Then too, there are the rarer back problems, such as congenital deformities (birth defects), mechanical causes, tumors, infections and circulatory problems. Chances are that you don't have any of these conditions. But whether or not you do, you should know a little about them.

Which Back-Pain Problem is More Serious?

It is difficult, perhaps even impossible to determine which bad back condition is more serious. As I've said before, you can't determine the seriousness of a condition by the severity of the pain. What I can tell you is that if you understand the nature of your back problem, you can take the appropriate action to speed your recovery, reducing the time your back has you down or uncomfortable.

By now you are thinking," Oh no, more anatomy. "And I guess you're right. I considered naming this chapter "The Anatomy," but thought I'd give you a break. In the next chapter, I will discuss body mechanics, which is an important element to reducing back pain. Then, in the following chapter, we will look at how to help your body heal your back. So, bear with me through this chapter, then we'll get on with making you feel better.

Before I get into this discussion of the causes of back pain, I'd like to try to impress you with a few more statistics. Unlike the numbers I gave you in Chapter One, these should give you some hope.

Seventy percent of all back pain sufferers will get better in two to three weeks, treated or untreated. Ninety percent of all back pain will subside in six weeks, no matter what. And three months is long enough for 98 percent of all back pain to disappear, even if the patient and the doctor don't do anything. These are not my statistics. They are the conclusions of many controlled studies done by several spine specialists over the

Causes of Back Pain

years. So, if you have back pain, chances are that you will get better within two weeks to 90 days, no matter what you or your doctor do.

Sound encouraging? Well, there's a few more things you should know . . . With each occurrence of a back problem, the chances of a more serious condition developing increase considerably. Even though it may be easy to shrug off the first one or two incidents, you will eventually have to face the problem. The other alternative is to put you and your family through a lot of unnecessary stress in terms of time off work, pain and inconvenience.

The Causes of Back Pain

For the sake of this discussion, I have separated back pain into five categories. These categories are:

• 1. Idiopathic Back Pain
• 2. Traumatic Back Pain
• 3. Degenerative Back Pain
• 4. Tension and Emotional Problems Causing Back Pain
• 5. Other Causes of Back Pain

Chances are, if you have back pain, I will discuss it in this chapter.

Idiopathic Back Pain

Idiopathic back pain is pain that can be directly related to behavior or lifestyles in otherwise healthy people.

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Good posture is essential to preventing back pain.

Poor Posture and Obesity

Often, poor posture and obesity can be attributed to a lack of exercise. To say that one or any of these will actually cause back pain is not always accurate. It is safe to say, however, that your chances of developing back trouble or having your current problem recur is less likely if you take the time to stand and sit correctly, lose weight and exercise.

Here's why.

When viewed from the side, the human spine curves like an S. Poor posture or excess weight increase the curves in the S, causing a condition known as kyphosis, or increase in the

Causes of Back Pain

thoracic curve, and lordosis, or increase in the lumbar curve. Changing, or applying undue pressure on the spine's curves increases the stress on your vertebrae, discs, ligaments and muscles.

Actually, poor posture and obesity put so much stress on the back that the degeneration process brought on by aging can be sped up. Poor posture and being overweight ages your back faster, allowing your back to weaken, which will make it more susceptible to injury. With all this undue, added pressure on your back, you are causing your muscles and ligaments to work harder. And, a lack of exercise allows muscles to atrophy, or loosen their support on your spine, further perpetuating the problem.

To sum all this up, standing and sitting properly (which we will soon be covering), staying trim and exercising your muscles will help you maintain a healthy, pain-free back.

Pregnancy

If poor posture and obesity can help cause back problems, well then it stands to reason that the same can be said for pregnancy. The excess weight and pulling of the pregnant woman's stomach on the bones, ligaments and muscles is similar, in terms of increased pressure on the spine. Of course, back pain is not present in all pregnan-

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cies, but woman who are either on the verge or already have problems, have a good chance of having back pain during pregnancy.

Overuse or Overexertion Injuries

The human body is subject to certain limitations. The back can stand only so much before problems arise. Overuse injuries in athletes are common. They can also occur in jobs where a lot

As you can see here, moving your back in one direction or the other

can cause overexertion injuries.

Causes of Back Pain

of lifting and bending occur. Remember that I said that overexertion is the cause of a substantial number of industrial lost-time injuries.

Different people have different limitations, but all of us eventually reach our point of overexertion. People who seldom use their backs are also susceptible to strains and sprains, because the muscles and ligaments in their backs are out of condition. I see many patients in my office who hurt their backs during moving or a weekend sports activity that they hadn't done in awhile.

Traumatic Back Pain

Traumatic back problems are usually the easiest to diagnose, because they can almost always be traced to a certain event, such as a car accident. There are several different types. Fractured bones are the most uncommon. The likelihood of fracturing a bone in your spine is rare. Your vertebrae is a well-constructed support system. It can withstand a great deal of shock or pressure without breaking anything. The discs between the vertebrae protect the bones from fracture. Injuries to the discs (which we will soon be discussing) are much more common. This does not, however, mean that it is not possible to break your back. Just as you can fracture bones in your arm or leg, you can also fracture vertebrae. That this does not happen often is good news.

Fractured vertebrae require a doctor's treatmentno if's, and's or but's. Spine fractures can cause a displacement or shattering of the bones and could lead to injury to the spinal cord, nerves, and possible paralysis.

Sprained Ligaments and Strained Muscles

Often, back injuries have nothing to do with bones or discs but instead with muscles and ligaments. (If you are thinking that these tissues are usually affected by overuse or overexertion, you are right.) This type of injury in your back is little

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different than when it occurs in any other area of your body. If you've ever sprained an ankle or pulled a muscle, then you know what I mean.

Ligament Damage

The ligaments and muscles in your back are very close together, often making diagnosis difficult. A sprained ligament is the result of stretching it beyond its normal capability. As with an ankle sprain, sprained back ligaments can happen with sudden twisting or bending. Since ligaments are the body's elastic bands that prevent excessive motion, when the maximum allowable movement has been reached, they become taut. Ligaments can stretch a little, but not much.

Sprains to ligaments can range from mild to severe. A sprain is considered mild when there is no real damage to the ligament. Severe sprains damage or tear the ligament. Either mild or severe, ligament sprains in the back can be stiff and painful. Mild sprains usually heal quickly, in a week or two, and require very little treatment. Severe strains, tears or other damage, will heal, but they often require a reduction in activity, even bed rest.

Usually, torn ligaments will heal. But sometimes they may not heal to be as taut as they were originally. Or scar tissue will form. Scar tissue is not as strong or as pliable as undamaged ligament tissues. Once-torn, ligaments are often more likely to be damaged again and very well could be.

Causes of Back Pain

Muscle Damage

Muscle sprains can also vary from mild to serious. Mild strains occur when the muscle unit is pulled or contracted beyond its limit, but no real damage has occurred. With mild strains, the muscle is still usable but it often will hurt. Severe strains, on the other hand, are usually the result of a tear in the muscle and can cause significant pain and dysfunction.

Spasms can also occur as a result of muscle injury. Spasms are the muscle's way of protecting itself from further use and possible further injury. Muscle spasms can also be associated with other problems, such as a ruptured disc or torn ligament. This is another way for the body to protect itself from further injury. Each time a muscle spasms, movement around the area is decreased, which protects the area from further injury or pain.

As with your ligaments, when muscles begin to heal, the pain and other symptoms begin to subside. If there has been a tear, scar tissue will form, leaving the muscle more vulnerable to a future injury. However, one way to avoid muscle or ligament injury is to exercise regularly so that these tissues don't weaken. It is also important that you do stretching and other warm-up exercises before engaging in strenuous activities.

Ruptured or "Slipped" Discs or Herniated Discs

Unlike some of the other traumatic injuries I've discussed so far, disc problems are not always the result of an injury-causing incident. Ruptured, slipped, bulging, or herniated discs, are just as often the result of degeneration, or aging, as we will discuss in a later chapter.

Many doctors, including myself, liken the spinal disc to a jelly donutfirm on the outside with jellylike matter on the inside. When, from too many years of bad posture, obesity, injury, aging, or wear and tear the pressure from the vertebrae gets too great, something has to give. This is an important and painful condition requiring a closer look.

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S lipped disc is another name for herniated or ruptured disc.

Contrary to the implication in the term "slipped" disc, discs rarely actually slip out of place. But they do bulge, rupture and herniate. A bulging disc is a disc that is bulging between the vertebrae. A ruptured disc is a disc where the supporting ring around the disc has weakened or torn. Herniated discs are discs where the rupture has gone one step further and the jellylike matter inside the disc has begun to escape.

Not only does the bulging or herniated disc cause pain, but it can also cause further irritation by pressing on the spinal cord or nerves. It is for this reason that people with disc problems in their backs also sometimes have pain in their buttocks, legs or feet. Often, the bulging disc will press on a nerve associated with these areas and fool the body into thinking there is something wrong there, too.

The nerve most commonly affected by this condition is the sciatic nerve. When a herniated or bulging disc puts pressure on the sciatic nerve, the nerve becomes irritated and sciatica occurs. Sharp, severe pains shoot up and down your back, buttocks, legs and feet. However, depending on the level of the back where the bulging disc occurs, the symptoms can be different.

For example, a herniated disc in the lower back can cause pain in not only in the thoracic region but also in the extremities; while a bulging disc in the neck can cause pain in the neck

Causes of Back Pain

and cause headaches. In fact, the symptoms from disc from problems are wide and varied, ranging from pain to muscle spasms, to muscle weakness in not only the back but in other areas of the body.

There was a time when disc problems were very serious, because they required drastic surgery to correct. Nowadays, however, treating disc problems has become much easier and less traumatic to the patient's health. I will discuss the treatment of herniated, ruptured and bulging discs in a later chapter.

In the mean time, let's take a look at bulging discs at the various levels in the back, their causes and their symptoms.

Herniated Cervical Discs

Neck pain from bulging discs is the price human beings pay for prolonged sitting, obesity, repeated bending, and whiplash injury from high-speed traveling accidents. If one or more of their vertebral disks rupture and press on the nerve roots, the pain radiating from the neck and down the arms can be incapacitating and severe. Additional symptoms can include sensory loss, tingling, numbness, and muscle weakness.

Side view of herniated cervical disk

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Top view of herniated cervical disk

Herniated Thoracic Discs

Severe, intractable mid-back pain from herniated discs can be the price human beings pay for high-speed accidents and degenerative disk disease. It can be painful and disabling. Thoracic disk herniation occurs less frequent than lumbar and cervical disk herniations. Often thoracic disk conditions fail to respond to conservative treatment and the patient lives with pain. In many cases, simple treatments such as heat, physiotherapy, rest, exercise, and pain medication bring relief. But other sufferers are not so fortunate. If one or more of their vertebral disks rupture and press on the nerve roots, the pain radiating along the chest and spine can be incapacitating and severe. Other symptoms often include sensory loss, tingling, muscle spasms, and numbness.

Causes of Back Pain

Side view of herniated thoracic disk

Top view of herniated thoracic disk

Herniated Lumbar Discs

Low back pain from herniated lumbar discs is the price human beings pay for walking upright and is providing the United States with a massive economic headache. If one or more of their vertebral disks rupture and press on nerve roots, the pain

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that radiates from the back and down the legs can be incapacitating. Other symptoms often include sensory loss, tingling, muscle spasms, and numbness.

Side view of herniated lumbar disk

Top view of herniated lumbar disk

Causes of Back Pain

Degenerative Back Pain

Throughout this book so far, I have used the terms degenerative and aging in several different places. Let me take this opportunity to tell you that as far as back pain is concerned, the words mean the same thingthe affects of the passage of time. As with every other part of your body, your back is subject to the normal wear and tear of life.

In this section I will discuss such degenerative conditions as arthritis, osteoarthritis and degenerative disc disease. Before beginning, however, I need to point out that these and other types of back problemseven though we have different names for themare often the same or so similar that differentiating between them doesn't seem to serve the focus of this book. It also is important that I mention that these conditions can often be related or are sometimes the results of other problems.

Wear and Tear

Although the process of aging is unavoidable, some symptoms of old age can be treated. And there are preventative measures that can retard the aging process. We will look at some of these later.

Wear and tear of the spinal bones is not much different from the wear and tear associated with other joints of your body. There are several conditions that I could discuss, though some don't occur often enough to warrant mentioning. Some of the most common are degenerative arthritis, central stenosis and lateral stenosis. These conditions are brought on by age, and are, naturally, more common in older people.

The next subsection of this chapter is devoted to arthritis. First lets look at a few less-common problems. The first twocentral stenosis and lateral stenosisare related in that both involve calcium deposits. The difference in these two conditions is where the deposits are located.

Central stenosis is a build-up of calcium around the spinal cord, which applies pressure to the spinal column. Lateral stenosis is a build up of calcium in the joints, which can irritate

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and compress nerves. Both of these conditions can cause not only pain in the back, but also, depending on the specific nerves affected, can cause pain in the buttocks, legs or foot.

Arthritis or Osteoarthritis

Degenerative arthritis, or wear and tear of the vertebral joints, causes inflammation, to which your body may respond by causing bone spurs. Inflammation and bone spurs can cause pain by themselves or by irritating other parts of the back, such as muscles, ligaments, spinal column or nerves.

This type of arthritis, sometimes called osteoarthritis, affects the joints of the vertebrae, and primarily the facet joints and between the vertebras themselves. The pain is similar to arthritis in other parts of the bodya dull ache. Like any other arthritic pain, spinal arthritic pain is aggravated by cold and inactivity.

Degenerative Disc Disease

Often, degenerative arthritis and degenerative disc disease accompany each other. The aging process generally affects both the vertebrae and the discs. Unlike the problems I discussed earlier about ruptured discs, degenerative discs are usually called flattened or bulging discs, seldom as ruptured or herniated.

Remember that I talked about the discs being the body's shock absorbers. It is the discs water content that gives them their resilience. With age, the water content in the discs decreases, the discs get smaller and lose some of their absorbance. The pain associated with degenerative discs is similar to that of arthritis, sometimes making the problem difficult to diagnose. Like arthritis, the aging process the discs go through is gradual. It is not always easy to remember exactly when the pain started.

Causes of Back Pain

Tension and Emotional Problems

Causing Back Pain

As I have tried to stress throughout this book, the body is an intricate mechanism. It is affected by all kinds variableslifestyle, diet, aging, and so on. Another very important component to your health is the amount of emotional stress you have in your life, and, of course, how well you deal with it.

Many emotional problems can add extra tension to your back muscles. Tension can cause a tensing of the back muscles, causing them to contract. Marital problems for example, are a common causes of depression. Depression can cause poor posture. All of the good body mechanics, diet and other health practices in the world won't help you if emotional problems and stress have gotten control of your life. Muscles react quickly to their environment.

Attitude

This seems like a good place to begin my little spiel about attitude. You'll be hearing this more than once from here on out; so get used to it. You cannot get control of your back problems with a negative or apathetic attitude. The program I will outline for taking care of your back in the next few chapters will require effort and enthusiasm. It will require you to really want to get rid of your back pain.

Often, back pain is just simply the result of a poor attitude about yourself, which is reflected in your lifestyle, the way you stand, sit, work, play. I have seen back pain occur as the result of a once-active person becoming inactive. Life is 99 percent attitude.

More on this later.

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Other Causes of Back Pain

As we move further down this list of back pain causes, these problems are seen in patients less frequently. The following back problems occur, some of them occur often enough not to be considered rare. But they are by no means the common cause of back pain; they are the exceptions.

Congenital

As a fetus and in the developmental years as a child, several things can occur which can cause back problems later in life. Congenital abnormalities of the back vary from insignificant to severe defects of vertebrae, spinal cord, nerves, muscles and ligaments. These problems can be painful, or they may not. Again, there are many, many variables.

The two defects I will discuss here are the most common. The first, scoliosissometimes known as curvature of the spineis a lateral or sideways curve in the back's normally straight, vertical structure. Often, scoliosis can be seen by examining the afflicted person's back from behind. This unnatural curve in the spine can cause pressure on the vertebrae, discs, spinal cord and nerves, which, as you already know by now, can cause pain.

The second condition is spondylolysis, which is a defect in the bone architecture of the spine that can allow forward slipping (spondylolisthesis). This condition usually affects one vertebrae or more. Spondylolisthesis, if severe enough, can cause a pinching of the spinal cord or nerve.

Tumors

Tumors or growthscancerous or notin your spine can cause back pain. Some of the problems are similar to those we've already looked at, the pinching or application of pressure to the spinal column or nerves. Cancer, of course, can be very painful. But then cancer of the back is very rare.

Causes of Back Pain

Infections

Like cancer of the back, infections of the back are rare. Infections can, however, involve the vertebrae, the discs or the spinal cord (meningitis). Infections in other parts of the body can spread to the spine. Some spinal infections can follow kidney or urinary tract infections. Infections can also occur as the result of back surgery.

Circulatory

Poor circulation can cause several back problems, including the thinning of bones and other tissues through a lack of proper nourishment.

Osteoporosis

Osteoporosis is a weakening and thinning of the bone through a decrease in the mineral substance. It occurs most often in the elderly and is the common cause of the stoop-shouldered condition associated in old age. The condition is most common in post-menstrual women. A certain amount of stooping is a normal part of aging; however, the process can be accelerated by hormonal, dietary defiency, and decreased activity factors.

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