ASK THE DOCTOR: Diet, exercise help reduce back pain
By DR. JIM MITTERANDO
The Patriot Ledger

Q. It seems like every year I strain my back. And all my doctor says is that I should lose weight and exercise. But what can I do to make my back stop hurting and keep this from happening again?

A. Sorry to break this to you, but your doctor is right on the mark by recommending that you lose weight and exercise.

This will take pressure off your back and prevent you from hurting it again. Exercise, even something as simple as walking, can help to increase your flexibility and strength and relieve stress. It's important to get rid of stress, because tense muscles are easier to injure.

Almost every adult hurts his or her back at some point. People like to pinpoint their back pain to a specific activity or incident - installing the air conditioner, moving heavy boxes, lifting kids, playing weekend sports.

What they don't realize is that most often back pain is the result of trauma that accumulates from everyday behaviors like bad posture while standing and sitting, being overweight and out of shape, and lack of flexibility. We also tend to bend at the waist instead of the knees when we lift a child or heavy object.

After years of doing things your mother told you not to do, your back gets hurt.
Back injury occurs most commonly from muscle strain or sprains of the ligaments supporting the back bones called vertebrae. The muscles of the back often then spasm to try to protect the back from further injury, which ironically, causes even more pain.

At this point a cycle of pain, stiffness and spasm can recur unless you work to decrease the inflammation, rest the back and gradually stretch the spasmed muscles.

In the past, doctors used to prescribe prolonged bed rest for back injuries. We've since learned that too much rest can actually make the back pain last longer, by promoting further inflexibility. The same is true for neck sprains and is why you don't see many people wearing those neck braces as was so common in the past.

I now recommend that people rest, at most, a few days if they have severe pain and resume stretching and sensible light activities as soon as possible to promote flexibility and quicker recovery.

Other causes of back pain include arthritis, which results from wearing of the joints between the vertebrae, and the notorious "slipped disk."

"Slipped" disk or herniated disk seems to be the best known and least common cause of back pain.

Disks provide cushioning between the vertebrae of the back. The disk can bulge (herniate) and press on a nerve coming from the leg or arm causing leg or arm pain, numbness, weakness or problems with control of the bladder or rectum.

Like most back problems, herniated disk pain frequently resolves spontaneously without surgery. In fact, 30 percent of people have herniated disks that have never caused any problems.

Getting relief

For relief of back pain, lie on your back on the floor with pillows under your knees, with your hips and knees bent. This takes the pressure off your back.

The treatment for all back pain is decreased activity for several days along with low back stretching exercises such as bringing your knees to the chest while lying on your back. It is also important to stretch your quadriceps (thigh muscles), which can contribute to back injury.

Use ice for the first several days to decrease the inflammation. Apply heat after the first several days if you have persistent muscle spasms. Anti-inflammatory drugs (NSAIDs) such as Ibuprofen (Motrin, Advil), Ketoprofen (Orudis) or Naproxen (Aleve, Naprosyn) all work equally at reducing pain and inflammation and may help in your recovery.

If one type does not work, then try another NSAID, since people respond differently to different drugs. Remember to take NSAIDs with foods since they can cause stomach ulcers.

The newer, more expensive, COX-2 drugs such as Vioxx and Celebrex work no better than older NSAIDs but may cause less stomach irritation and are normally recommended only for long-term pain or for people with a history of ulcers.

Acetaminophen (Tylenol, non-aspirin) may not help the inflammation but can help with pain and does not cause stomach upset. Acetaminophen is the safest for long-term use, but don't take more than 2,000 to 3,000 milligrams a day because high doses can affect the liver.

I am not a big fan of muscle relaxants and feel they don't work for most back pain.

You don't need an X-ray

People often ask me whether they need X-rays or MRIs. Most back pain does not need any study. X-rays may be useful if a bone injury such as fracture from trauma, osteoporosis or cancer is suspected. X-rays are not helpful for the majority of back pain since it does not visualize soft tissue such as muscle, ligaments and disks.

We only use MRIs when considering surgery or further evaluation of intractable pain. MRI is not necessary for most herniated disks since it does not change the treatment, which includes rest, stretching and possibly physical therapy.

When back pain does not improve, I recommend either physical therapy, chiropractic treatment, acupuncture, yoga, massage therapy or epidural steroid injections, depending on the nature of the injury.

Chiropractic treatment seems to sometimes help back pain for reasons not well understood. I do not believe the chiropractor's theory of "putting bones back into alignment" because muscles support the bones of the back and we need to work the muscles and posture to maintain good back health.

See your family doctor if you have back pain that is not resolving after several weeks or if you have weakness or numbness in an arm or leg. Surgery is rarely required for back pain or herniated disks, because long-term outcomes tend to be the same whether you have surgery or choose less invasive treatment.

Try yoga

I believe yoga is the best treatment for chronic back problems because it promotes proper posture, stretching and breathing, and decreases stress and muscle tension. Many patients have told me that yoga has helped when other treatments have failed.

After back pain improves, it is important to exercise, lose weight and work on muscle strengthening and posture. Half-situps with the low back remaining flat against the floor work the abdominal wall muscles and are excellent prevention for future back problems.

If upper back pain troubles you, try pull-down exercises on a Nautilus machine or pull your shoulder blades together and hold the position for several seconds at a time.

My favorite exercise for posture consists of placing your feet 12 inches from a wall and leaning against it, sucking in your abdomen, and sticking out your chest to flatten the back against the wall so that the back loses its curvature and the head, shoulders, back and pelvis are all aligned.

This resembles the "at attention" posture of soldiers. Hundreds of years ago it was known that soldiers could stand for hours without back pain if they had good posture. Your mother knew this, too, but unfortunately she cannot follow you throughout the day and poke you in the back to remind you to stand straight and sit properly in the car and at work.

Dr. Jim Mitterando is a family doctor at Health Care South/Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.

Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.

Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.

Copyright 2001 The Patriot Ledger
Transmitted September 18, 2001