"Oh my aching back!" It's like an old refrain. "Back pain is a universal experience," says Dr. Greg Peterson, Medical and Outpatient Rehabilitation Director of the Bone, Spine, Sports Clinic in Bismarck, North Dakota. "There is no way to prevent it," adds Dr. John McCulloch, FRCSC, Chief of Spine at Summa Health System in Akron, Ohio, comparing it to gray hair, "It's caused by age and genetic encoding--we can't do anything about it." Its causes are nebulous, says Peterson, "There are no tests that tell exactly where back pain comes from. Different experts have different points of view--a chiropractor refers to spinal alignment, a physical therapist deal with muscles and posture, a neurologist focuses on nerves and an orthopedic, bones and discs."

Though we may not fully understand, or be able to stop it entirely, the medical profession is answering the call of the over 6 million patients who annually seek medical treatment for back pain. St. Charles Hospital in Ft. Jefferson, New York, in conjunction with the Stony Brook University Hospital, recently formed a Back & Spine Center to address the multi-faceted problem. According to Dr. Craig Rosenberg, Medical Director of St. Charles Hospital, Rehabilitation Network, "Back pain is the nation's leading complaint. The Center was formed to approach back pain from a Bio-Psycho-Social model, bringing together various perspectives to better diagnose and treat back pain." Dr. Raphael Davis, Chief of Neurosurgery at St. Charles further explains, "We have a unique approach--the cause of pain could be other than just the back. Our doctors have a wide range of expertise, and all are crossed-trained to understand back problems and prescribe various courses of treatment." Patients at the Back & Spine Center have intake evaluations by a panel of 2-3 specialists, who compare notes and create an adjustable treatment plan.

One medical specialty, Physical Medicine & Rehabilitation (PM&R), also uses a multi-faceted approach to back pain, however, they do not perform surgery. These doctors, often called physiatrists, specialize in the musculoskeletal system and use patient history and physical examinations to find the source of pain or disability, even when diagnostic tests don't reveal specific problems. Further, PM&R physicians coordinate with other services such as physical therapists and athletic trainers, for individualized and comprehensive treatment. Peterson explains the stages of treatment, "First we treat pain, to get the patient out of misery, using anti-inflammatories and muscle relaxants. Then, we get them up and moving. Rest is important, but it is better to move to prevent muscle atrophy and depression. In physical therapy and treatment, we try to observe how the person moves, so we can correct posture and mechanics to minimize stress on the spine. We also deal with the psycho-social factors that effect the pain. Preventing back pain is not just about flexibility and strength--it ties into overall well-being."

There are two basic types of back pain--the first centers in the back, often lower back, while the second radiates into the legs, frequently called sciatica, and usually indicates that a disc or bone over-growth is pressing on a nerve. Both types of back pain are treatable. According to Dr. Jahan Joubin, a Board Certified Orthopedic Surgeon, practicing in Woodbridge, Virginia, "The body adapts. If you lose weight and exercise, and stop smoking and drinking, the pain can be treated without surgery." McCulloch concurs, "You can get better on your own, with physical therapy, exercise, medication and often, by losing weight. If the pain doesn't get better and there are functional limitations, then surgery becomes an option. And though McCulloch is a surgeon, he cautions that any physician who recommends surgery should assure the patient that the least invasive method should be used. "There is a tendency to be too aggressive," he comments, suggesting a second opinion when instrumentation, a procedure that inserts rods or screws to support the spine, is prescribed, "A patient should hear that from at least two surgeons--not just one. With such extensive surgeries, in the long term, you're not going to be well," he warns. McCulloch, a microsurgery specialist, recommends for patients under 35 years of age, procedures like chemonucleolosis, the injection of papaya juice into a joint, which he says has an 80% success rate. However, he attests to a 90% success rate for microsurgery. Because the procedure is so precise, performed under a microscope, using much smaller incisions, "It causes less trauma to tissues and is better for the patient," he states.

Most doctors and therapists agree that in addition to the aging process which causes ligaments to thicken, cartilage to lose its cushion and discs in the spine to degenerate, the most common links to back pain are repetitive actions, or overuse, lack of exercise, smoking and being overweight. Most also concur that state of mind is paramount, citing anger about an injury or depression, as blocks to healing. States Rosenberg, "Rehabilitation can be very uplifting, but the patient has to accept responsibility and want to get better. In a depressed state, you don't heal. If your job is miserable, it becomes part of, and validates your pain. 'Psychosomatic' doesn't mean that you don't have pain in your back--it means there are factors beyond tissue healing--the mind and body play games with us."

"Smoking is very detrimental," McCulluch emphasizes. "It decreases the oxygen supply to all tissues, specifically the back." "It is the biggest risk factor," states Peterson, "The small blood vessels that give nutrition to the disks are impaired and though there are few factors that really show a direct correlation to back pain, smoking is a definite cause."

Christopher Wise, Director of Physical Therapy at Phoenixville Hospital of the University of Pennsylvania Health System, states that most of his patients are injured workers with over-use problems, caused by repetitive actions performed on assembly lines, in piece work, or lifting. "These types of actions are beyond the body's limits," he explains, "Therapeutic exercise to enhance strength, balance and flexibility is helpful, but therapy needs to relate to the function--it's like football players being in shape for their season." Wise, who is also a certified athletic trainer, uses ultrasound, moist heat and ice to relieve pain and inflammation, but believes exercise is the key to recovery, and encourages patients to continue to work on their therapy at home, "It's their responsibility to help themselves--to improve their quality of life," he states.

The growing prevalence of "repetitive strain injury" (RSI), prompted Rosenberg to join Sandra Peddie in writing her book, The Repetitive Strain Injury Sourcebook. Strains occur not just from work, but from avocations and routines as well, and Rosenberg sometimes suggests that patients keep a diary to help identify what causes the problem. The book cites posture as one of the most significant factors, since, "Poor posture feels comfortable." Sedentary workers, truck drivers who sit for long periods of time, and people who sit at computers, often suffer. "The body is designed for movement," Peddie explains, "... muscles forced into a static position ... don't perform rhythmic contracting and relaxing ... Soreness can result." Rosenberg recommends ergonomically designed work stations and chairs with proper back support, where knees are level, or slightly above the hips. Positions vary for each individual, but the feet should rest on the floor, and if the chair is too high, he suggests putting a phone book under your feet and using a small pillow to help support the lower back. It is most important that the body maintain balance--the primary factor in overall back health.

Most therapists use various forms of lumbar stabilization exercises to help patients find their own balanced or neutral position, where weight is distributed evenly, and the natural curve of the spine is maintained. Such posture, or pelvic tilt, requires strength in the abdominals, back and thighs. According to Rosenberg, "It is important to maintain conditioning and flexibility, especially in the quadriceps, hamstrings and hip rotators." Joubin recommends bicycling for strengthening the lower body, and stretching exercises, like laying on the floor and tucking the knees to the chest. Richard Nyberg, a Board Orthopedic Certified Specialist suggests adding range of motion to the above stretch by rotating the knees from side to side. He cautions that stretching should be done with a focus, to be beneficial. "Tissues don't lengthen unless the body is relaxed, so breathe deeply and stretch effortlessly in a yoga-like method to get the most benefit," he explains.

Paul Juris, a kinesiologist and sports training and rehabilitation specialist from Sandy Springs, Georgia compares balancing the trunk of the body to a stack of blocks. "If you slide one block in one direction, you have to move another to create symmetry." Juris recommends stretching to keep the lumbar spine flexible and revamping daily habits like talking on the phone or carrying a heavy brief case, on one side. "As a rule of thumb, if you do something on one side that causes imbalance, the body can equalize if you do the same thing on the other side." Perhaps we should call that, "a rule of back!"

Ask for assistance when needed.
When lifting from the floor, keep the back straight, avoid bending at the waist and use the legs to rise from a squat position.
Get close to the object to be lifted.
Don't hold your breath. Exhale as you lift.
Avoid pulling or twisting as you lift--use the legs to pivot.
Move slowly, plan your movement, think before you do something.
Maintain good balance with firm footing.

Stand with knees slightly bent, with weight distributed evenly.

Use the abdominal muscles to tilt the pelvis, flexing and extending the lumbar spine to attain a balanced position for optimal function and stability.

Contract the abdominal muscles to maintain the position. Feel the tightness of the abdominal muscles with the fingers.

Square the hips and shoulders, imagining the spine, hips and shoulders as a single unit. The body can move in a variety of postures and activities while maintaining this stable posture.

Number of Patients Annually Visiting Office-Based Physicians for Back Problems 6,087,000
(Injuries 2,224 Disk Disorders 877,000 Other back conditions 2,987,000)

Number of Patients Annually Hospitalized for Back Problems 468,000
(Injuries 73,000 Disk Disorders 254,000 Other Back Disorders 141,000)

Number of Surgical Procedures 273,000
(Removal of disc, chemonucleolysis or other destruction of intervertebral disc) 160,000
(Spinal Fusion - Fusing 2 or more spinal segments without removal of vertibral disc)

Data extracted and analyzed by American Academy of Orthopaedic Surgeons, Department of Research and Scientific Affairs, Rosemont, IL, based on most recent 1995 annual figures.