Back Pain, Mechanical

By Dr. Sawatzky

In the last two columns I introduced the problem of back pain and briefly looked at some of the specific causes. However, in the vast majority of people with back pain no specific cause for the pain can be found.

There are many theories and hundreds of different treatments. It is a fact that most people at some time during their lives will experience significant back pain. Chiropractors, physiotherapists, massage therapists, and others spend a lot of time treating back pain. There are hundreds of specialized back clinics and institutes. Back pain is the single most common reason for workplace absenteeism, and it seems to becoming an even more common problem. What is going on?

The following is my own personal perspective on this problem. That does not mean that it is Ôright', just that it is my current understanding in this area. I have had a personal interest in this problem since childhood. When I was about 12, I was playing touch football and I was running for a touchdown. An opposing player closely followed me and I attempted to put on that last little bit of speed to get across the goal line when I experienced sudden and severe low back pain. It settled over a couple of weeks but I have had chronic, intermittent, low-grade back pain since then.

When I started backpacking as a teenager, I noticed that I had extreme lumbar lordosis. When I straightened my lower back as much as I could, I still had enough room to put my entire arm between my lower back and the frame on the backpack. While weightlifting in high school, I experienced sudden, severe low back pain that settled over a few weeks with treatment by a chiropractor. By this time I figured my extreme lumbar lordosis could not be good and I started working on my stomach muscles and posture to straighten out my lower back.

When I was 30, I bent over to pick up a tissue from the floor. I had sudden severe low back pain. It was so severe that I could only curl up on the floor in agony for 30 minutes. I was unable to crawl 15 ft to the phone! It settled over a couple of weeks. Several years later I picked up an empty plastic snow shovel and had the same problem. Last fall, age 48, I took off my shoes and while standing up had the same experience but this time it completely recovered in a few days. I have also experienced several other similar episodes.

X-rays are completely normal and MRI shows only a slight central disk bulge at the lower lumbar vertebra (a meaningless finding). In between these experiences I have been extremely active, was a national level weightlifter, participated in gymnastics, spent 20 years in the military including 2 years with the Airborne Regiment, and currently workout regularly and do fairly extreme caving, climbing, cave and technical diving, etc.

So what is wrong with my back? After 35 years of recurrent problems I still have no idea, and I have seen lots of Ôexperts'. Unfortunately, my experience is EXTEMELY common and most of you reading this will have had similar, hopefully less frequent and severe episodes.

I spent much of my 20 years in the military treating people with low back pain. I also spent some time doing independent medical assessments for insurance companies (a totally thankless task) where I saw a lot of people with serious back problems. I may not know what causes the problem, but in the vast majority of people I know how to treat it successfully.

Some background information. When I was a medical student in the 1970s, severe low back pain was treated with up to six weeks of bed rest. The results were terrible. Several very well done studies have shown that if a person with sudden severe back pain goes to a chiropractor or medical doctor, the results are equivalent, and poor. The person who recovers the fastest is the one who takes a maximum of two days rest, a couple of days of increasing activity, and then goes back to work and full activity. Last fall when I had my problem, I had no choice but to stay in bed for two days as I was unable to stand up! The third and fourth days I was up and about the house (still lots of pain) and the fifth day I was back at work. The sixth day I went back to the gym to workout and within a few days I was back to my normal exercise schedule.

Treatment of acute, mechanical low back pain I think is quite clear. Chiropractic manipulation has virtually no benefit and in some cases can be harmful. Drugs are largely ineffective. Up to two days of rest followed by rapid return to full duties works best. But, how can we reduce the likelihood of recurrence and how can we get rid of the chronic, mild back pain so many people suffer?

About 10 years ago I heard a fascinating speaker at a conference. He made more sense talking about back pain than anyone else I had ever heard. I talked to him after the meeting and ended up working with him over the next few years. He was a medical doctor who had spent several years working with a chiropractor and very difficult back pain patients. Together, they had developed what was to me a new and unique approach that had excellent results.

They discovered that people with bad back pain always had a back that did not function properly. These backs had reduced or unbalanced flexibility, reduced or unbalanced muscle strength, loose pelvic ligaments, or some combination of these problems. Their approach is conceptually very simple. They examine the person's back to find out how it is functioning and to rule out a serious problem. If there is no serious problem identified, they prescribe a specific program of stretching and exercise to normalize the function of the back. In virtually every case, as the person's back function returns to normal, the pain is either dramatically reduced, or completely eliminated.

There are several important points to remember. The first trick is that everyone is different. There is no one program of stretching and exercise that will work for everyone. Some people need to improve their flexion, others need more extension. Some need stronger stomach muscles (almost everyone), others need to focus on the lateral trunk flexors.

The second even more important point is that back pain can only be successfully treated by the individual becoming more fit and working to improve their flexibility and muscle strength. We have to get up out of our chairs and go to the gym and exercise!

Does this approach work for me? Yes. Most of the time I am completely pain free, and certainly I have no limitations on what I can do. When I miss the exercise program for more than a week, I get mild low back pain that goes away with a couple of days of exercising. Why the bad episode last fall? I had been traveling a lot, had not been doing my regular exercise program, and paid for it! At least I recovered quickly.

The bottom line is that rest is the WORST thing you can do for chronic pain of any type, especially the back. Reduce your weight to a healthy level, do daily stomach exercise and stretching, develop a general muscle strengthening workout three times per week and a good aerobic workout (30 to 45 minutes) at least three and preferably five times per week. If you need some help deciding what to do, any fitness trainer can help you develop a good general workout. If you are over 40 or have any known medical problems, check with your doctor to ensure that there is no medical reason you cannot engage in a vigorous exercise program. Start slow and increase the level of exercise gradually. Expect it to take 6 to 12 months to get into reasonable shape. If this approach leads to ongoing or increasing back pain, you need to change your stretching and exercise routine until the problems have resolved.

Good luck! I'll see you at the gym.