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Back

Five years ago, Margaret's back kicked up painfully and she panicked. She's an active woman, and a bad back seemed to threaten all her favorite pursuits--long hikes, daily aerobics classes, bike rides down sleepy morning streets. She cut down on her exercise just a smidgen. Then she trekked from doctor to doctor, searching for a diagnosis and a cure.

But the diagnosis she finally got seemed vague: The doctor said she was suffering from muscle strain. The cure--ibuprofen and modifying her exercise program--seemed, well, wishy-washy. And the pain got worse, no matter what she did. Even bed rest didn't help. Then, when she resumed her workouts, the meanest pain of all--sciatica--started traveling from her back, along one side, from her buttock to her foot.

Margaret decided to give up all exercise until the sciatica subsided. Some days later, she took a ten-minute tentative nonpowerwalk. In the days that followed, she gradually increased her pace and walked longer distances. Eventually, she resumed biking, hiking and even aerobics classes. True, she didn't take double aerobics classes, and she carefully alternated activities instead of stressing the same muscles. But the woman who thought her exercising days were over was cured. Her back pain never flared up again.

Why didn't it? What exactly had happened? What cured her? And what had caused the pain in the first place?

She was never really sure. Both the cause of the problem and the reason for her recovery were a double mystery to Margaret.

Getting Adjusted

If you go to a chiropractor for treatment of back pain, you can expect many of the usual doctor things. A chiropractor takes a medical history, does a physical examination, orders lab tests and sometimes does x-rays. (You might not have x-rays right away, however; some doctors and chiropractors say you don't need x-rays unless the symptoms continue for four weeks or more.)

Once the diagnostic part is over, the chiropractor will do a spinal manipulation, making adjustments of your spine on a special table built for that purpose. The goal is to realign your spine so that muscle and bone can move normally and start to heal. It's a hands-on experience.

"Basically, the chiropractor pushes or pulls different parts of the spine to improve muscle and joint function," says Scott Haldeman, M.D., D.C., Ph.D., associate clinical professor of neurology at the University of California, Irvine, and adjunct professor at Los Angeles Chiropractic College in Whittier. "When the chiropractor moves into a spinal adjustment, she usually gives a short thrust to the spine with the heel of her hand. And you commonly hear a click or a pop. That means there's been some movement within a joint."

A History of Mysteries

Far from being an isolated case, Margaret's experience with back pain is typical. As often as 80 percent of the time, the cause of back pain is a mystery, says John D. Loeser, M.D., professor of neurologic surgery and director of the Pain Center at the University of Washington School of Medicine in Seattle. "We can't make a definite diagnosis except for a small fraction of the people who come to the office."

With 31 million people in the United States bearing the burden of bad backs, plenty of doctors are looking for answers. Only the common cold prompts more office visits than the common backache. In fact, 70 percent of American women will have back pain sometime in their lives--usually before they're 50.

Of course, it's understandable that a part of the anatomy with so many complex moving parts would prove to be a troubled zone. Beneath its smooth skin lie muscles ranging in size from the huge lats (latissimus dorsi) that surround the chest area to the little teres minor muscles that pull your upper arms toward your shoulder blades. A cat's cradle of tendons and ligaments helps the muscles support the 26 bones of the spine.

The back is complex, efficient and wondrous. But there is a lot that can go wrong. Muscles can pull or tear, and stress can tense them up for easy damage. Ligaments might sprain; tendons can strain. Ill use--poor posture, bad lifting techniques, lack of exercise--can insult our backs. Even when we don't damage them through injury, eventually, age wears down the back's spools of bone, along with the shock-absorbing disks between them.

The Back Doctors

Although studies show that chiropractors are often consulted for acute back pain, many other medical specialists also treat backs. Though their titles are different, many of their methods are similar. In fact, "at this time, many of the treatments prescribed by different specialists are coming together in agreement," says Edward Hanley, M.D., chairman of the Orthopaedics Department at Carolinas Medical Center in Charlotte, North Carolina. Here are the front-runners for back treatments.

* A chiropractor, or D.C. (Doctor of Chiropractic), focuses on manipulating the spine into proper alignment, relaxing muscles and increasing motion to relieve abnormal pressures in the back. Many also prescribe physical therapy exercises, although they cannot prescribe drugs.

* A neurologist is an M.D. who focuses on the diagnosis of neurological disorders.

* A neurosurgeon specializes in spinal surgery.

* An orthopedic surgeon is a medical doctor (M.D.) or D.O. who has specialized and can treat any problem of the musculoskeletal system and can operate. Some prefer to call themselves orthopedists to highlight the nonsurgical component of their practice.

* An osteopath, or D.O. (Doctor of Osteopathy), can practice spinal manipulation, prescribe drugs and perform surgery, if she has specialized in orthopedics or neurosurgery.

* A physiatrist is also an M.D., one who specializes in rehabilitation medicine and physical therapy.

* A physical therapist, or P.T., is licensed in physical therapy, but she cannot prescribe drugs. Physical therapists are expert at prescribing therapeutic exercises for backs and at checking proper posture.

Relief Happens

So it's no mystery why the back is a mystery. Even the federal government has acknowledged that the healing of bad backs is a complex process with no pat system of recovery. When the federal Agency for Health Care Policy and Research reviewed 3,900 studies of treatments for back pain, it found only a few of the treatments to be scientifically valid. Even such established programs as traction, steroid injections and acupuncture don't hold up to rigorous scrutiny.

In fact, the agency's guidelines for health come down to something like this: Take two aspirin and don't call the doctor in the morning. For nine out of ten people, researchers found, back pain--even acute back pain--goes away on its own within a month as mysteriously as it came.

If you're wondering whether you're someone who definitely needs to see a doctor for back pain, "the danger signs are weakness or numbness in the legs or loss of bowel or bladder control," says Jeffrey Susman, M.D., member of the U.S. Public Health Service Agency for Health Care Policy and Research and vice-chairman of family medicine at the University of Nebraska College of Medicine in Omaha. If you don't have these or other uncommon difficulties, however, symptoms usually disappear--and without a clue to their cure.

Does that mean there's nothing you can do? Not at all. According to experts, there are quite a few relief measures that help the majority of bad-back sufferers. The first one probably sounds familiar.

Take two aspirin. Sure, the advice is old. But it's also tried-and-true. "The safest, most effective drug is probably in your medicine chest," says Dr. Susman. "Aspirin proved to work as well as anything stronger--like muscle relaxants. So did acetaminophen and ibuprofen. And they don't have the side effects of strong prescription drugs." If aspirin or ibuprofen, which are both anti-inflammatories, upsets your stomach, you can use acetaminophen.

Get your spine in line. The only other clinical method of treatment offering relief for back pain is the spinal manipulation that chiropractors perform. (Osteopathic doctors also do spinal manipulation.) The federal study found that spinal manipulation works especially well in people who have some level of acute back pain--the kind that comes on suddenly and doesn't last very long--notes Scott Haldeman, M.D., D.C., Ph.D., associate clinical professor of neurology at the University of California, Irvine, and adjunct professor at Los Angeles Chiropractic College in Whittier. But he did say that studies are being done that indicate spinal manipulation also helps people with lingering chronic back pain.

Get up and at 'em. One of the traditional treatments for back pain--bed rest--got thoroughly trounced in the federal guidelines. Bed rest that exceeds four days weakens your muscles and bones and impedes your recovery, warns the panel. Most experts advise that you get no more than two days of bed rest--tops.

Get Better with Yoga

Two yoga exercises, the yoga sit-up and the mountain pose, both help relieve back pain, according to Mary Pullig Schatz, M.D., yoga instructor and author of Back Care Basics. Here's how they're done.

BACK 1A-1 Yoga sit-up. Lie on your back with your calves resting on a chair seat as shown in the illustration, bottom left. Your hips as well as your knees should be bent at 90-degree angles. Cross your arms in front of your chest and place your hands on your shoulders.

Yoga sit-up--starting position

Inhale and exhale slowly as you press your lower back to the floor and flatten your abdomen. Raise your shoulders six to ten inches off the floor and hold. Lower your left shoulder to touch the floor and then raise it back up as shown in the illustration, bottom right. Then lower your head and shoulders back to the floor. Repeat the sequence, using your right shoulder.

Continue the exercise until your abdominal muscles feel warm, then do one or two more sit-ups and stop. Be sure that you don't hold your breath during the exercise. It's important to inhale and exhale steadily in order to avoid straining. BACK 1B Mountain pose. Stand barefooted, with your feet five to eight inches apart, placed directly under your hips. While keeping your upper body erect, bend your knees so they move forward over the center of your feet as shown. There's a tendency for the curve of your back to increase in the lumbar area, which is the small of your back between your rib cage and pelvis. Try to keep this curve constant, so your abdomen doesn't "pouch" forward. Inhale, then exhale, and as you exhale, slowly push your feet into the floor and straighten your knees. (But don't lock your knees in place.) Hold this position for 30 to 60 seconds, breathing normally.

Practice this standing posture as often as you can during the day. BACK 1A-2

Mountain pose

Yoga sit-up--left shoulder lowered

"Inactivity is bad for the body," says Dr. Loeser. "Don't go home to bed. Resting until you feel better is likely to make you worse. Bed rest is deleterious to your health."

"Get up and get active," says Dr. Susman. "Plan an early return to activity." That means as normal a work schedule as you can manage and low-stress exercise such as walking, swimming or biking.

Make love, not hurt. How to snuggle with your honey when your back hurts is a topic that comes up often with patients, says Dr. Haldeman.

"I remember one patient who used to come in on Mondays with horrendous back pains. They'd improve during the week after an office visit. But every Monday the woman would be back in my office again. It started to get expensive, so her husband got a little angry, and he came in one Monday with her. He turned out to be six-foot-four and about 300 pounds. She's five-foot-two and 110 pounds. And they had sex every Saturday and Sunday night.

"I asked them what position they used, and they said the standard one. I said, 'Well, it's time to change the position.' No way that woman could handle all that weight.

"As a rule of thumb, the person with back pain should be on top during intercourse and in control of the movement and pressure," he concludes.

Back-ercise

If there's any miracle cure for back pain, it's exercise. But the key is sensible exercise--not Margaret's version of ten aerobics classes a week. "You do need regular aerobic exercise for back health," says Dr. Susman.

Holding the Line on Posture

Mom was right when she told us to sit up. Absolutely correct when she told us not to slouch. On the mark when she said to stand up straight.

Posture may sound old-fashioned, but it's a big back deal. When we slouch, swagger or sprawl, we skew our joints out of alignment. Being pushed out of their natural places stresses and strains them.

"Just sitting round-shouldered puts tremendous mechanical stress on the ligaments, soft tissues and muscles in the back," says Wayne Rath, P.T., co-director of Summit Physical Therapy in Syracuse, New York. "It's been established that there is 300 percent more tension in that position than in sitting up with a normal curve in the back."

The key to perfect posture? According to Mary Pullig Schatz, M.D., yoga instructor and author of Back Care Basics, the rules are straightforward: "As much as possible, keep your ears over your shoulders, your shoulders over your hips and your hips over your knees and feet."

To check out your own alignment, just look at yourself sideways in a mirror. You should be able to draw a straight line all the way from your ears to your feet, as shown above.

Practice Makes Posture

Most of us need a few reminders to keep our posture looking good. Here are some simple tricks and cues that can chase out the slouch and get you upright again.

Beanbag it. Remember when growing girls used to practice good posture by walking with books balanced on their heads? Dr. Schatz suggests a similar--but much less BACK 2 precarious--maneuver: "To become more aware of how to maintain erect posture, sit, stand and walk with a bag of dried beans or rice on your head."

S-T-R-E-T-C-H. If you're trying to break the slouching habit, the stretch shown at right is especially useful for desk-bound workers. "Get up every 15 minutes, place your hands in the small of your back and lean backward," says William Case, P.T., president of Case Physical Therapy in Houston. Hold that position for a few counts--it reverses a slouch. It also reminds you to sit straight in a chair--just like your mother told you to do.

Pinch it. Case also recommends shoulder pinches. Stand up and clasp your hands behind your back near the waist. Lift your hands and stretch backward. Try to pull your shoulder blades together. Hold the stretch for a few seconds.

In Good Standing

Another way to be kind to your back is by paying attention to how you stand. The more erect, the better. Here are some tips for maintaining a good standing posture.

Wear good footgear. Running shoes are best, but of course you can't wear them all the time. So, for work and dress, alternate your flats, low pumps and--if you must wear BACK 4 them--high heels. "High heels may aggravate your back--they increase the curvature and affect your gait," says Case.

Raise a foot. If you're standing in one place for a long time, look for something you can put a foot on, just to elevate a leg and change your position. If you're standing by the sink or folding clothes by the dryer, put one foot on a stool. Waiting in line for a movie, find a ledge or curb. If you're in a grocery store, put one foot up on the front rung of the shopping cart when you're waiting at the checkout line.

"You know why there are foot rails at the bottom of bars?" asks Alan Bensman, M.D., medical director of Glenwood Rehabilitation Center in Minneapolis. "Bartenders knew that people would stand at the bar and drink longer if they could put one foot up on the rail and be comfortable."

Don't bend and brush. When you bend from the waist with your legs straight, the tension tugs at your back muscles. It's the typical tooth-brushing position, though. To avoid straining your back while you're brushing your pearly whites, open one door of the cabinet under the sink and rest your foot on the ledge. Or use a footstool.

Perfect posture. Note that ear, shoulder, hip and ankle are all aligned.

Shoulder pinches. With your hands in the small of your back, lift or push your hands slightly upward and lean backward for a few seconds.

Laid-Back Ways to Sleep

Even sleeping has some rules. When it comes to avoiding back trouble, here's what experts advise.

Sleep on your side. The ideal sleeping position is often the fetal one, with a pillow between your knees and with one or both knees slightly bent, says Alan Bensman, M.D., medical director of Glenwood Rehabilitation Center in Minneapolis. If you do sleep on your back, place a pillow under your knees. Keeping your knees flexed, however, may make your hamstrings tighten.

Stretch before rising. Before you get out of bed in the morning, it helps to get ready. Lying on your back, hug one knee at a time to your chest and hold it that way for five seconds, giving your back a chance to stretch. Then roll onto your side and push yourself up with your arms. Swing your feet onto the floor and greet the morning, says Dr. Bensman. When you get out of bed, attempt to keep your back as straight as possible. Then try arching your back once or twice, holding for five seconds each time. Also, you can rotate your back to the left side and hold for five seconds, then rotate to the right and hold for five seconds.

Update your mattress. Buy a new mattress and box spring every seven to ten years. They don't always show their wear, but mattresses and box springs exhaust themselves, too, after 20,000 to 30,000 hours of your Zzzs, according to Louis Sportelli, D.C., a chiropractor in Palmerton, Pennsylvania, and director of public affairs for the American Chiropractic Association.

Use a bed board. If your current mattress sags and you're not prepared to invest in a new one, tuck a bed board between the box spring and mattress to firm it up. The Care Catalog Services in Portland, Oregon (1-800-443-7091), offers both regular bed boards for the home and portable bed boards you can take along on trips. You can also put the top mattress on the floor or get a futon for the floor, according to Mary Pullig Schatz, M.D., yoga instructor and author of Back Care Basics.

Lifting position. Bend your knees, not your back.

As you lift, keep the package close to your body.

Moderate exercise can also help prevent a recurrence of the pain if you do it regularly. As you get fit, your back and abdominal muscles that support your torso grow strong and resistant to injury. Not only do they armor and protect the spine, they also protect tendons and ligaments by absorbing stresses that might irritate those soft tissues.

If your back spasms or cramps easily when you make a sudden move or attempt a long reach, exercise will probably banish that pain, too. Weak, underused muscles (or overused muscles) are the reason for cramps or spasms, as all the fibers in the core of the muscle contract at once. Movement releases the fibers of a cramped muscle, but the fibers of a muscle in spasm stay locked for a while.

Walking Away from Back Trouble

"Walking, swimming or cycling can be excellent exercises for your back," says William Case, P.T., president of Case Physical Therapy in Houston.

An increase in overall physical fitness can decrease occurrences of back injury. Improved physical conditioning increases the postural muscles (in the back, buttocks, abdomen and legs) that you need to maintain peak posture, the foundation of solid backs.

It's best to begin walking within two weeks of the first onset of symptoms, most doctors agree. You don't have to wait until you're totally pain-free, but do start your program slowly. Try ten-minute walks every other day and work your way up to a half-hour or full hour as you feel better, suggests Dr. Loeser. You might even enjoy walking daily.

Working Abs for Your Back

The abdominal muscles in the front of your trunk and the back muscles behind them form a kind of corset that supports your back. That's why back experts recommend strength-training exercises that target both the back muscles and the abdominal muscles that counterbalance them.

"You shouldn't work the back muscles to the exclusion of the abdominal muscles," warns John J. Triano, D.C., staff chiropractor at the Texas Back Institute in Plano. "You need to train in a balanced manner, or you set yourself up for further problems."

The abdominal crunch and the single-arm row (see pages 448 and 446) will help you firm up some fine support.

Back-Smart Living

Life has lots of booby traps for backs. Whether you're raking the yard, vacuuming the carpet, toting a heavy handbag or driving a car, pain can pounce when you least expect it. Before you turn your back on these harmless-looking troublemakers, here's how to prevent pain from starting.

Check your tool technique. When you're working with a rake, vacuum cleaner or broom, stand up straight when you use it. When you're raking, for instance, don't extend the rake out in front of you so that you have to lean over to reach the leaves. When you're sweeping, keep the broom close to your body. When you vacuum, use the long wand of the cleaner--don't bend over the short one.

Put your purse on a diet. If you routinely stuff your handbag full of magazines, makeup, sunscreen, hand lotion, keys and coins, lighten up. It's probably a good idea to use a backpack if the weight of your purse noticeably causes an increase in back pain, says Case.

A backpack may be an alternative to a heavy purse because it balances the weight on your back. With a heavy purse you usually favor one side. (It's not the only factor, however--the way you hold your body and move when walking can also aggravate a weak back.) Without proper body mechanics and good posture when walking, you can still aggravate a weak back. If you do wind up carrying a hefty bag, shift it occasionally to the other side so you don't strain your back, suggests Case.

Bolster your curve. Many people who drive mega-miles carry along a "lumbar support": That's a fancy name for a very simple cushion or roll that supports the small of your back, which is the lumbar area. You can buy the cylindrical support in a medical supply store.

Rolls come in different diameters, so find a chair or take it out to your car and test the support before you buy. You can also make your own lumbar roll by rolling up a towel smoothly and wrapping it with tape. Try out different sizes and different types of towels until you find one that offers support to your lower back when sitting and feels comfortable against the small of your back. The roll should fit in the small of your back, providing some pressure on the area and helping you to maintain the natural arch.

Fidget. "The majority of people slouch when they're sitting for long periods of time. That's when the muscles supporting the lower back become tired and weak. A slouched posture puts additional stresses on the ligaments of the spine, which results in pain," says Case. To relieve the stress on the back, all you need to do is stand and move around. If you want to ease the stress while you're sitting, just roll up a towel and place it behind your lower back to provide some support.

When you're on a long trip in a car, try to stop every hour or so to exercise your back. Walk around outside your car a little. If you're in a plane or train, shift your rear end from side to side, wiggle your feet and tighten your abdominal muscles to realign good posture and give your back muscles a break.

Fidgeting for better circulation helps when you're in a car, too. The beaded wooden rollers that fit over the seat make it easy to move around a bit even while you're driving. "They're pretty neat," says Case. "They can give your back a massage effect if you move around on them." You can usually buy these roller-bead seat covers at auto supply stores.

Laid-Back Ways to Sleep

Even sleeping has some rules. When it comes to avoiding back trouble, here's what experts advise.

Easing Your Sitting

If you're not sitting properly, you're putting increased demands on your lower back. "Bodies were made to move, not sit," says Case. Here are some tips to take the load off when your back is under pressure, according to Mary Pullig Schatz, M.D., yoga instructor and author of Back Care Basics.

* When you're flying, ask the flight attendant for two pillows. Put one behind your back and put the other one under your feet. (After takeoff you may want to substitute a briefcase for the foot rest if you're more comfortable that way.)

* On long bus rides try using the foot rest.

* Don't cross your legs. It creates uneven weight on your hips and pelvis and throws your back muscles off balance. If you can't kick the habit, switch legs often.

* Don't sit on soft couches or in deep chairs. Softness may feel like comfort, but your back needs support.

* Try out a rocking chair for back comfort. (President Kennedy always used one to help ease his back pain.) When you're rocking, you're using your legs, and that stimulates circulation.

* Another alternative is the "kneeling" chair, such as the Balans chair, which has one cushion for the knees and a second, firm cushion that supports the buttocks. With no back or arms, it may be hard to get used to, but it's a very good chair for tasks where you tend to lean forward, like microscope work or sewing. The design of the chair helps keep your spine erect.

* Place your keyboard so that you don't have to raise your shoulders to type. Ideally, your elbows should be positioned at a 90-degree angle when you're working.

* For activities where you tend to lean back slightly--such as reading or watching television--use a chair with an adjustable low-back support. Or make sure you use a rolled-up towel or a lumbar roll to support the curve in the small of your back.

Large economy sizes of soap powder and cat litter are thrifty--but not smart if you strain a back muscle lifting them. Buy the smal

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