Candi Spencer had a car accident last August. Her car was hit from the rear, pushed into the vehicle ahead of her and “bounced back and forth a couple of times,” she says. Unfortunately for Spencer, a waitress in her 30s, the accident’s legacy continues.
She injured her back badly enough that the pain forced her to curtail the number of hours she works. In addition to losing income, she spent weeks going from doctor to doctor in an effort to find exactly what happened to her back.
“I went to one, a neurosurgeon, who just pinched me with a little pin and didn’t do anything,” Spencer says. “I was sent to physical therapy, but they didn’t know what was wrong with me. They more or less did massage. It didn’t help and may have caused more of a problem. And this was certainly at a reputable hospital.”
Then she consulted an orthopedic surgeon who ordered X-rays, but they were negative. She then was referred to a doctor specializing in rehabilitation medicine.
That doctor ordered a course of physical therapy-which still didn’t result in much improvement-then ordered a magnetic resonance imaging scan. The sophisticated, expensive test revealed the source of the problem was a compression fracture in a vertebra in the middle of Spencer’s back.
Spencer says that with a diagnosis, the physical therapy she now is receiving is helping her. “I need to strengthen my back muscles, but I’ll have that fracture for the rest of my life,” she says. “It affects my ribs and my head. I get pain in my ribs, mainly on my left side. I get shooting pain down my left leg. The injury also caused curvature of the spine and a sacroiliac dysfunction (involving connection of lower back to pelvis), which will be a problem when I bear children.
“The pain is kind of always there, but it’s something you get used to after a while. It’s depressing, but I know there’s people out there with worse problems than mine.”
The problem of back pain is common. It affects up to 80 percent of adults at some time in their lives and is the second leading reason people see physicians. By some estimates, back pain costs the nation as much as $50 billion a year for medical care, worker’s compensation payments and time lost from the job.
“Back ailments can be due to a number of different scenarios: physical strain from a job, improper posture during sitting, upper back pain combined with carpal tunnel syndrome from working at a computer terminal, or low back pain secondary to degenerative changes in the back, which occurs as a function of aging,” says Dr. Bob Goldman, president of the National Academy for Sports Medicine and chief physician and surgeon for the sport of bodybuilding.
“It is a very common problem and one that will continue, and that’s why there’s a huge market for back rehabilitation as well as the huge pharmaceutical industry for painkillers and anti-inflammatory medication. And there are a lot of health practitioners in this field.”
Back pain, especially lower back pain, can be one of the most complex medical problems to handle.
“Most people have an inciting incident that they can relate to the onset of their current disorder,” says Dr. Fred Geisler, a neurosurgeon who heads the Comprehensive Spine Care Center at Columbus Hospital’s Chicago Institute for Neurosurgery and Neuroresearch. It’s a full-service, interdisciplinary center that treats most patients without surgery and uses medication judiciously.
A fact of aging
“Most folks also will have chronic changes, visible on X-rays, that predated that event. It’s related to the aging process. The joints grow older, the bones age and change some of their configuration with aging. The discs start out with a lot of water content and dehydrate as life goes on. It’s the clinical manifestations of these changes that we experience as pain and possibly dysfunction.”
There is no quick fix for a spinal disorder, Geisler points out. “A major emphasis we have here is that you’re a partner in taking care of your back,” he says. “It’s not like you take your car in and get a new carburetor. Surgery is reserved only for the most extreme cases, and even with surgery you have to do the proper exercises and care for your body afterward to mimimize your chances of having further problems.
“The disease process on the spine turns out to be episodic. You never really get over it. It’s something you have to continually work on for the rest of your life. The natural history of it is that there are flareups, separated by many years or, in some people, separated by just a few months.”
The structure of the back begins with the spine and spinal cord, from which nerves branch to the rest of the body. Ligaments tie the vertebrae to one another and muscle tendons pass from vertebra to vertebra and from there to the pelvis, ribs, shoulder blades, arms and skull. Therefore, when there’s a problem, its origin may be difficult to pinpoint. And even with a firm diagnosis, the array of treatment options available, from surgery to exercise, massage, acupuncture and chiropractic manipulation, makes for more confusion for consumers.
Last fall, the Agency for Health Care Policy and Research, an arm of the federal Health and Human Services Department, announced a three-year study to evaluate the effectiveness of three options: spinal manipulation by a chiropractor; the McKenzie method of physical therapy, which emphasizes extension of the spine; and an educational booklet about back care.
Next year, the agency is expected to publish the results of a study begun in 1989 to analyze back surgery practice variations and examine alternative ways to diagnose and treat low back pain.
Middle-age spread
When sudden back pain occurs, people often suspect a “slipped disc” (cartilage displacement), but most backaches probably aren’t caused by disc problems. Sometimes they’re caused by something as simple as excess weight.
“It’s common in our society for people in their 40s and 50s to cease to be athletic and put on extra weight,” Geisler says. “Then the musculature is not balanced. If you put on extra weight in your abdomen, this is carrying you forward. Your abdominal muscles, which hold the anterior portion of your spine straight, are not that functional and competent. That puts you into poor posture, puts stress on the bones themselves and causes them to deteriorate.”
Catherine Kujawa Irwin, a physical therapist at the Lincoln Park Physical Therapy Center, says that a lot of back pain is the result of “years of moving improperly, years of bad posture and sitting.
“And a lot of people who may have done gymnastics and ballet or diving when they were young have problems when they hit 35, 40, 45, 50. They were putting abnormal loads on their spine and it gives up on you later.
“It’s the same thing with golf. Golfing is the worst, because the worst position for your spine is when you rotate. It puts the most torque on it. People who golf tend to have a lot of back pain.”
Irwin also cites studies and personal experience with patients indicating that “job dissatisfaction and nicotine are correlating factors in lingering back pain. Smoking decreases your circulation, so you have less oxygen in the back and less healing. People who hate their jobs are depressed and unhappy and they don’t get better as fast as others.”
Most of the patients using the Lincoln Park Therapy Center initially consulted neurosurgeons or orthopedic surgeons, though some visit internists and chiropractors and occasionally naprapaths (whose treatment involves manipulation of ligaments, muscles and tendons), according to Irwin.
Working the body
“Once in a while we have a back or neck patient who is just not getting better even though they’re doing everything they can and so are we,” she says. “Sometimes we will refer them to a chiropractor or an acupuncturist.”
Irwin also says she is an advocate of various massage techniques, especially Rolfing, for back pain. Rolfing, a bodywork method devised by biochemist Ida Rolf in the 1920s, involves deep manipulation of the fascia (connective tissue that supports the skeleton and muscles) to restore the body’s alignment, resulting in better posture and balance.
Something as simple as unequal leg length can result in back pain because the discrepancy causes the pelvis to be uneven and the spine tilted to compensate. It can be treated simply by using a lift inside the shoe of the shorter leg, or with bodywork, if it is not an anatomical abnormality.
“Most of the cases of unequal leg length I’ve encountered are functional, not anatomical,” says Bob Kearney, who practices structural therapy, a technique similar to Rolfing, at the Lincoln Square Natural Health Clinic. “You can have legs of unequal length that are the result of tight musculature that pulls the legs and causes them to rotate. If the leg rotates, it’s functionally shorter.”
Once regarded as heresy by the conventional medical community, chiropractic now is virtually mainstream. An extensive back-pain study-done by a team of Canadian health economists-made public last fall concluded that spinal manipulation by chiropractors is more effective, safer and more cost-effective than other treatments for low back pain.
Classic chiropractic treats back pain and other conditions with spinal manipulation on the theory that dysfunction is caused by interference with nerve function. Many contemporary chiropractors, however, are not simply adjusting the spine.
“I treat the musculature as well as the structural spine because the muscles attach into the spine,” says Loop chiropractor Anne Gordon. “If you treat them together, you tend to get quicker results. Patients here also go into a stretching program and a rehab program to learn how to strengthen the back.
Non-drug treatments
“Treatment here consists of a wide variety. We do some physical therapy modalities. We do different muscle stimulations. We use ultrasound. I’m also a licensed acupuncturist and will use acupuncture in some cases. The biggest portion of treatment is manipulation of the spine and relieving dysfunctions of the spine that are tied in with muscle spasms.”
Those who want to avoid drugs and surgery are often attracted to chiropractic care, which is conservative. “I know that I have a degenerating disc,” say Jeff Livingston, 38, a computer consultant.
“Medical people will tell you that an option is surgery to remove the disc and fuse two vertebrae, depending on how bad the problem is. Over the last two years with chiropractic care, I’ve seen a difference in how the disc looks on X-rays, an improvement. I would like to avoid surgery. I have a healing problem as a result of diabetes, and conservative treatment is less risky for me.”
