Why does back pain hurt so much?

I know you well. I see you a couple of times per week. Sometimes I see you a couple of times per day.

Your back hurts.

http://www.sweetsharings.com/2013/04

You are the young dad who threw your back out this weekend wrestling with your kiddo right after helping your buddy move a piano up to his second-floor apartment.

Or perhaps you're the very pregnant lady who cannot find a comfortable place to stand or sit or lay down or basically exist in the world because your back is killlllling you.

Or you're the vineyard worker, hauling huge crates during crush without a proper moment to adjust your body mechanics.

Or you're the mom of a twenty-five-pound toddler who insists on being carried most hours of the day.

Or maybe you are the middle aged dude who commutes two hours five days a week and whose back will not forgive you this month, even on days you avoid the car entirely.

Or perhaps you are an amateur athlete training for a big event next week with a little zinger that moves from your mid-back down your leg.

Or you're a waitress. . .or a student. . .or a nurse. . .or a programmer or a writer or a baker.

Whoever you are, your back hurts, and you join lots and lots of fellow humans, who at some point in our lives, will suffer from back pain.

Back pain is common
In fact, 25% of adults report having had back pain for at least one whole day in the last three months. Back pain can be miserable (serious misery), and though many people with back pain do not seek medical attention, studies show that 1in 10 primary care visits is for  back pain

As a family doctor, I see about 18 patients per day. That means I see 1.8 patients per day with back pain. And most people with back pain are unhappy-- they are so unhappy that they have taken time off work, ridden their horse three hours bareback, and hired some scary babysitter to watch their kids to come and see me.

Little me.

That's a lot of pressure (on me).

And a lot of pain (for you).

And to be perfectly honest, I hate your back pain almost as much you hate your back pain. Give me an ear ache or strep throat or a funny looking mole or even a broken arm any day. I can fix those (or at least make you feel better) even before you leave my office. The problem with back pain is that there is no quick fix, and, quite honestly, that sucks (sorry, Mom-- she hates that word).

I know very well that when people come to the doctor for back pain they are always 1) in a lot of pain and 2) scared.
 

Just before I knock on the exam room door for a "back pain" visit, I often find myself wishing for a magic rock, fairy godmother, any god, even a mind-altering substance-- knowing any of these modalities will make the pain and the fear go away quicker than I will be able to. Unfortunately, my wish is never fulfilled. Instead, I summon up my own empathy, compassion, and good listening ears. These are my  most effective doctoring tools-- especially when it comes to back pain.


Here's the scoop on most back pain
1) Back pain, particularly low back pain, is super duper common. As I alluded to above, between 70-80% of adults will experience back pain at some point in their lives. Each year, between 6% and 15% of people will experience back pain for the first time. I'm sorry. I feel you. I've been there.

2) Most people don't go get seen by a doctor when their back hurts. 

3) Back pain usually rears its evil head in people between the ages 20 and 50, with the highest rates in people in their forties.

4)  Most often back pain fits into 1 of 4 general categories: non-specific low back pain (that's most people), pain with radiculopathy (radiculopathy is doctor-speak for pain that radiates somewhere, most often down into the back of the leg, often referred to as sciatica), spinal stenosis (pain caused by the spinal cord getting scrunched inside the vertebrae, most common in older people), and back pain as a result of another "spinal" cause (this is a catch-all category including most of the very scary things that people worry about when their back hurts, e.g. the big "C" metastatic cancer, spinal infection, fractures, etc)

5) Back pain usually goes away (check this out: 54-90% of the time it resolves with absolutely no intervention)

6) But then it often comes back (recurrence rate ranges between 24-80%). Sorry.

7) Doctors often don't know how to make patients feel better

(I know, this is exactly what you didn't want to hear. In a recent study of almost 24,000 patients with back pain (1999-2010), doctors were found to be prescribing less anti-inflammatories and acetaminophen and increasing opiate medications (e.g. vicodin, oxycontin-- 19-29% of the time), even though the studies consistently show opiates don't do a better job for pain. The same study also showed an increase from 7% to 11% of patients getting an MRI or CT scan to evaluate their back pain, even though there is really good data discouraging providers from doing so.

8) First line medications for back pain are acetaminophen (aka generic Tylenol) or non-steroidal anti-inflammatory medications (in doctor-speak NSAIDS, including ibuprofen, naproxen, motrin, etc).

9) X-rays, MRI, and CT scans are not actually therapeutic. They do nothing (I repeat "nothing") to make you feel better. However, requests for these imaging studies are an important reason people make doctor's appointments. There is something about the human psyche that makes people believe that getting that MRI will make them feel better. I have no idea what that is.

10) You should probably only get an MRI/CT scan if you are considering surgery (or epidural injection). If you are one of those "No way in hell, doc, is anyone operating on this virgin spine" people, then trust your doctor NOT to order you an MRI. Why?

When even the doctor is scared
Of course, there are (rare) cases when back pain can actually be scary. Here are a few examples of what health care providers call "red flags"-- things that make us worry your back pain could be something worse than run-of-the-mill-every-day-back-pain. Please do note that these red flags are NOT perfect. In fact, more than 80% of people will have at least one of these red flags with their back pain and still have run-of-the-mill pain, but if someone has more than two, a provider will likely be more thoughtful about the evaluation.

• A personal history of cancer
• Recent unintentional weight loss (over 20 pounds in the last 6 months)
• Age over 50 or under 17
• Not getting better, especially after 4-6 weeks
• Persistent unexplainable fever (>100.4)
• You inject drugs
• You have new problems controlling your bowels and/or bladder

There are many more in the list of red flags, but you get the gist. A good health care provider will probe a bit to be sure he/she isn't missing a more serious diagnosis. This is just one more reason to have a personal relationship with your primary care provider--it's double advantageous for your provider to know you and to ask the right questions.

For all of those patients who DON'T have red flags, here's my doctor shpiel for routine I think I might die back pain.

I'm sorry, back pain is evil.
I'm sorry, I am so glad I am not you right now.
I am sorry, I know it feels like you are going to die.
But this IS going to get better.
It really is.

And in the meantime, after you are done cursing your body and your provider, please consider:

1) Anti-inflammatory (NSAID) or acetaminophen for pain, whichever you find helps most.  (I hate to tell you, but Vicodin and all its bed brothers (e.g norco, percocet, oxy etc) do nothing for back pain. They just numb you against the evil unfairness of being in pain. Such numbness might seem helpful, but can also be risky). 

2) Rest (though rest just for a little bit-- in the good ol' days, people with back pain used to be sent to bed for days-- research has found that prolonged immobility makes back pain worse). You shouldn't be lifting those giant bags of rocks or cleaning your bathtub tonight, but hopefully you can get back to those activities in a short amount of time. Gentle walks are a good idea.

3) Ice/heat (whichever your prefer, don't believe anyone who tells you there is actual evidence that one or the other is better). The choice is yours.

4) Time (and time's best buddies: patience and trust)

5) In very certain circumstances of acute spasm (e.g. your boy friend lying frozen on the ground saying, "I cannot move, I cannot move, do something"), just a few short days of muscle relaxant might be indicated (like cyclobenzaprine or baclofen or diazepam). My patients know I am stingy with these guys-- just a few days worth can sometimes do the trick. Talk to your provider.

6) Core strengthening is always a good idea. It probably does nothing to help your acute back pain but may prevent recurrences by taking some of the stress off your overloaded back.

7) Restructure your work station (too much sitting is FAMOUS for causing low back pain, often screens are not appropriately set, etc) or your work environment. Often it's something you are doing 6 or 9 or 11 hours a day that's really driving your back mad. Change that!

8) Consider physical therapy and integrative modalities if you cannot seem to kick the pain-- my personal preference is osteopathic manipulation (OMT), an amazing medical modality that is gentle and actually works for many people. Look for doctors who have a D.O. after their name, instead of an M.D. and be sure to ask them if they practice osteopathy.

9) Stay in shape. Seriously.

So, at the end of the day, do I actually have any idea why back pain hurts so badly? Sorry to tease you with the catchy title, but I don't. I have to admit I just don't. But it does.  The good news is, for most of us, it will go away with a little time, some attention to behavior change, and good self-care. And if it comes back, start at the beginning and do it all over again.

It will work!

To end, an attempt at back pain haiku, because, well, why not?

Back aches, gnaws, screams, squeals
Lies down in deep dark silence
Where pain has no voice

 **

Stand up for patience
Time and change, may you be well
The pain will pass soon


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Additional References:
http://www.ncbi.nlm.nih.gov/pubmed/21665125
http://www.ncbi.nlm.nih.gov/pubmed/1477891
http://annals.org/article.aspx?articleid=736814
http://www.aafp.org/afp/2012/0215/p343.html#afp20120215p343-b2
http://www.fpnotebook.com/ortho/sx/LwBckPnRdFlg.htm
www.npr.org/blogs/health/2014/01/13/255457090/pain-in-the-back-exercise-may-help-you-learn-not-to-feel-it