Why do our backs ache? UW researchers look for answers

What physical ailment—suffered by 85 percent of all adult Americans—is often regarded in the Third World as nonexistent: major back problems.

“When it comes to backs, we are really a Third World country,” says Dr. Stanley Bigos, director of the UW Medical Center Spine Resource Clinic.

He cites a 1987 study of an Arabian culture where back problems were not perceived as either an injury or a potentially disabling condition. What’s more, the Arabs’ back problems did not seem to require medical assistance.

Compare that with the United States, where the number one medical complaint involves the back. More money is spent on treatment, sick leave, disability and lost income from back problems than any other single ailment. According to the National Center for Health Statistics, money spent on back problems surpasses all funds spent on AlDS patients, a condition expected to last into the foreseeable future.

Indeed, 85 percent of all adult Americans can remember episodes of back pain. Physicians stress that our complaints are not unfounded or contrived. The cultural differences express a different attitude toward back problems. And that attitude lends itself to treating the back differently—physically and psychologically.

The structure of the back explains a lot about where and how back problems can occur. For most people, the real problem does not begin in the back itself, even though that is generally where victims report discomfort. The spine is both protected and supported by a series of muscles that extend around to the abdomen. If these muscles fatigue easily or are weakened from improper or little activity, the back loses its muscular support and protection. A disc may become displaced and irritate nerve elements. Further weakening of muscles can occur through inactivity, which can worsen the problem.

“Beyond that, we really don’t know much about how the back works,” says Bigos. “Of all the back ailments we see, we clearly understand only about 12 percent.”

Although many Third World populations don’t believe back problems need medical attention, they do experience problems with their backs. But “in other countries, they do not expect to be disabled, only slowed in certain tasks when their backs are ailing,” says Bigos. Their rehabilitation continues with performing normal tasks, only slower and over a longer period of time.

So someone from Bangladesh and someone from Bellevue with the same back problem may respond differently. Why does one person maintain some degree of activity, while the other insists that any activity is impossible?

“Psychosocial problems of the back patient must be looked at just as closely as the physical symptoms,” says Dr. Stan Herring, a sports medicine physician and clinical assistant profes­sor in the UW School of Medicine.

“It’s not that the pain is contrived by people who are unhappy with their jobs or relationships, but these are major influences on what affliction may exist,” he adds. “The person who is basically happy with his or her life will not experience the additional misery suffered by the individual who is discontent with a job, a relationship or living situation.”

Bigos agrees. “Frequently, there is a link between back problems and problems on the job,” he says. The victim may not be happy or feels like a failure. “No doubt they have back problems. Half the work force reports back symptoms. But exactly how the individual responds to his or her back problem can depend heavily upon the situation.”

Dr. Richard Deyo confirms his colleagues’ points. The associate professor of medicine and health services at the UW School of Medicine says, “There is always an emotional response to a problem which translates into an emotional element of an illness. We can’t overlook it.”

Herring continues, “The physician must be capable of examining the whole person, of taking a closer look at the impact of the person’s job and relationships, before treating any back complaint.

“As it is, by and large, the medical community overreacts to back ailments. Back problems are over-medicated, over-rested and over-operated. Ninety-nine percent of all back troubles can be rehabilitated without surgery, but last year more than 300,000 back operations were performed in the United States.”

Deyo heads a team that recently received a $5 million grant from the National Center for Health Services Research to study the processes of diagnosis and treatment used by American physicians and surgeons. “The medical literature on surgery for back pain may be unique,” he says, “because of its extensive commentary on failure.” While most surgical journals focus on successful techniques, entire volumes have been written on the “Failed Back Surgery Syndrome,” he reports.

“The need for uniformity in both the diagnosis and treatment of back problems is paramount,” insists Deyo. “The processes for both diagnosis and treatment vary from one area to another in the United States. In some parts of the country, hospitalization for nonsurgical care is popular; in other regions, there is an emphasis on outpatient attention. Our research will seek to discover which is more likely to be successful.”

Economic status can also play a role. “Poorly educated people have more hospitalizations for back pain than well-educated people, with worse outcomes,” he says.

Upon its completion, the study should indicate methods of dealing with the total needs of the patient, not just the physical or medical treatment. Deyo hopes to discover ways to reduce unnecessary surgery, hospitalization and other related costs while successfully meeting the needs of the patient.

Along with conventional care, the study group plans to look at other methods of treatment, such as chiropractic care. In fact, there is a chiropractor on the research team’s advisory board.

Herring feels that surgery must be only the very last resort for back problems, and then only for specific conditions. Bigos emphasizes the importance of not rushing into surgery.

“Surgery can be dramatic, but in many cases,” he stresses, “chances of recovery are dropped to less than half of what they would be by doing nothing at all.”

“Tom” is a classic example of back surgery gone wrong. The Seattle man now has a sedentary job, following an active career in law enforcement. He had experienced a couple of minor back pain episodes after some altercations with suspects and after a motorcycle accident. Then one day he jumped off a low fence in pursuit of a suspect, and his back seemed to “give out” on him.

Tom went through a series of doctors and treatments. He took narcotics, faced nearly four weeks of bed rest, and followed strict orders to limit activity. Then he underwent physical therapy and traction (20 minutes pulling on his head, followed by 20 minutes pulling on his waist). At this point he was now experiencing neck problems from the traction as well as back pain.

Back on the job, his back “gave out” for the last time. The police department took him off the force.

This was followed by an exhaustive examination. A dye was injected into his spine and results indicated a herniated disc. The treatment: operate and “fuse” the vertebrae above and below the disc. The operation did not “take.” He wore a back brace for some six months but was in worse pain than ever.

This was followed by another operation that included using screws inserted into the bones of his spine and the installation of batteries with wires. This procedure went awry. Nerves were damaged in the operation and his right leg became hypersensitive; one of his feet turned purple and swelled far beyond its normal size.

Tom says that his personal life nearly fell apart because of his frustration. He and his wife were on the verge of divorce during the most unsuccessful period of his back treatment. He does not like his sedentary job, but he has come to grips with the fact that he will never return to the job he says he loved: being a cop.

The batteries, wires and screws still show up on his X-rays, but since he has been under the care of Bigos, Tom says he is actually making progress. Bigos took him off narcotic painkillers and put him on a regular regimen of physical activity, building Tom’s abdomen and back muscles. He’s walking, riding on a stationary bicycle, doing some light weight training—all of which, he says, are helping his psychological outlook. “I can see the light at the end of this tunnel,” he says.

Sports medicine specialist Herring says many people are mistaken if they think back pain results from physical work or leisure activities. “Most people have gradual episodes, which increase in intensity, and then there is one distinct episode that makes people feel like their back ‘gives out.’ It can range from stepping off a curb to being tackled in a game.”

Herring has some good advice for anyone who is experiencing episodic back symptoms. “These symptoms do not disappear,” he warns. “They almost always intensify until that one, impacting move. If you begin to experience problems, work out a good rehabilitation program (yes, rehabilitation, even though the symptoms seem minor) for yourself, then stick with it. This can help you avoid more serious problems in the future.”

Deyo, Herring and Bigos all agree that the patient must be a partner in his or her health care, particularly when it comes to the treatment of the back. With the proper exercise and care, our backs can serve us well—and without pain—during our lifetimes.

How to avoid a “back attack”

If you want to have a healthy back, you should follow a personal program of physical activity designed to strengthen your abdominal and back muscles. Here is a compilation of tips from experts associated with the UW School of Medicine.

  • Practice using good posture. Your mother’s tirade to “stand up straight” was good advice after all.
  • Practice using a good sitting position.
  • Reduce sitting time as much as possible.
  • Use isometric exercises (exercises you can perform sitting or standing in place) whenever possible if you work at a typewriter, computer or cash register.
  • Walk as much as possible. You may want to try speed walking.
  • Lift things properly. Crouch down. Pull the item as close to your belly button as possible, then lift with your legs, not your back.
  • Cycle, either exercycling or bicycling, or swim.
  • Take a good, low-impact exercise or yoga class.
  • Take the stairs instead of the elevator.
  • Take regular breaks from whatever activity you perform (sitting, standing, lifting or pulling) over an extended period of time.
  • Ask for help when you need to lift or move heavy items.
  • Respect your back and your body. If you are getting older, don’t try to act as if you are still 18.
  • See a physician you respect to help you put your personal exercise regimen together.

When in pain:

  • If you are experiencing back problems, avoid staying in bed for extended periods of time; strong medications; overly restricting your daily activities; operative procedures for back problems (always seek more than one opinion if surgery is suggested); and sitting for long periods of time.
  • If you do lie down, restrict the period of time you rest.
  • You may want to lie flat on your back, elevating your knees with a pillow.
  • Use only mild painkillers, such as ibuprofen or aspirin.
  • If you life on your side, you may want to use a small cushion between your knees, and be certain to elevate your head with a pillow.

If back pain is accompanied by other symptoms, your condition might need professional treatment. Here are some clues indicating it’s time to call your doctor:

  • Pain or numbness traveling down the leg.
  • Weakness in the foot or leg.
  • Pain that does not improve after a week or two.
  • Symptoms that seem unrelated to back pain.

Back to Nature: Comparing Dogs, Cats and Humans

Why are human beings so apt to suffer from back pain? Are we alone in this misery? No, say anatomy experts, but the way we suffer is different from other animals.

For example, four-legged creatures like cats and dogs do not suffer any lower back conditions (the ones we are most likely to experience). They do, however, have other types of back problems, some of which can be fata.

“One breed always at risk is the dachshund, because the longer the spine, the more gravitational pull on it. That means there is more dynamic ‘loading’ of the spinal column due to jumping on and off beds or furniture as well as in and out of cars,” says Dr. Kenneth Sinibakli, a Seattle member of the American College of Veterinarian Surgeons.

Cats, dogs and other four-legged species have a spinal cord (which carries the nerve center) contained throughout the length of the spinal column. The human has a spinal cord that ends about two thirds of the way down the back. The reason we hurt mostly in our lower back is because we injure the nerve roots there (not the cord itself). This leads to more pain, but less paralysis.

Pity the poor dog or cat. It takes more of a blow to injure them, but a back injury has a more serious and debilitating outcome than for the human.

The disc is the cushion between vertebrae. When there is pressure from the inside (coming from the spinal cord), that pressure can push the disc out of place, causing it to herniate. That, in turn, will pinch nerves in the human, resulting in pain. The herniated disc in your pet can cause paralysis.

Still, animals tend to be easier on their backs than we are. Dogs and cats recline a lot. We tend to sit. Sitting is something you will never see an animal do for a long period of time.

Walking on two legs presents its own problems. The spinal column is always loaded and discs can herniate because of the pressure on the disc base in the lower back. Interestingly, walking still remains one of the best exercises to keep the back in good condition because it also strengthens abdominal muscles.

For both animals and humans, the key to keeping a back in shape is a good combination of activity and rest. Animals are usually active when they are up and about, and reclining when they rest. Mostly, they need to avoid traumatizing their backs from high leaps and injuries, and we need to avoid traumatizing our backs by keeping the supporting muscles in good shape and avoiding unnecessary impacts.