Back school is in session.

It’s time for a little celebration. You’ve cleared the half-way point in BackCare 101 and are nearing completion of the program. This lesson is devoted to helping you ace your back program. If you have any questions about the information, skills, or exercises you've been gathering and doing since Lesson One, take the time to go back over those lessons for a review now.

You learned early in the program simple ways to take care of your back pain by applying heat or ice, by positioning your back for comfort, and by using healthy back postures. You began exercises to help you move and function easier. And you learned the importance of using your core muscles during activities like lifting to protect your back from further pain and injury.

You'll find in this lesson that most back pain usually goes away quickly. Unfortunately, most people who have back pain once will have it again. Scientists estimate that as many as 90 percent of back patients will have recurring back pain, which returns again and again. That's why it is so important that you learn and apply ways of controlling symptoms when they happen. But even more importantly, your back program is designed to give you the knowledge, skills, exercises, and resources to improve your chances of avoiding recurring back pain.

Most people who have first-time back pain get better in a matter of days or weeks. They usually don't need any special or sophisticated tests (such as X-rays or MRI scans) unless concerns, or "red flags," are raised. Later in this lesson you'll learn what these red flags are and what should be done if they appear. In rare cases, specialized medical tests may be needed, along with further treatments, if symptoms don't go away as expected.

Specific Instructions on “Nonspecific” Low Back Pain

Back pain is rarely life-threatening, and it's usually not from a serious disease. In fact, most people who have back pain for the first time get better in a matter of a few days to several weeks. So relax! And breathe deeply. By doing so, you'll be on track to ace your back pain.

When back pain first occurs, the pain can set you back for a short time. At first, you might even need to take a break from activities for a short while. But as you learned in Lesson One, it's generally a good idea to get back to daily and work activities sooner rather than later.

Many people who have a first go-round of back pain will have back pain again within a couple of years. Still, the problem isn't necessarily serious, and people can generally return to normal activity in a short amount of time. But just because your back pain isn't serious doesn't mean you should ignore it. It is important to try and understand it.

Most often, back pain is a mechanical problem. As we pointed out in the last lesson, mechanical back pain tends to occur with activity and eases with rest. Although it starts in the low back, you may feel it spread into one or both buttocks. It rarely goes down past the back of the knee. Your back may feel stiff in the morning, and your pain may feel worse as the day goes on.

The first time this type of back pain strikes, healthcare providers may refer to it as "simple" or "nonspecific" back pain. You may think the pain is anything but simple! However, you need to understand that this type of problem is not serious. It simply means your back isn't moving and working normally. You haven't damaged your back. You probably won't need any special or high-tech tests to figure out what's going on. Hopefully all you need is our reassurance that you're going to be okay. With BackCare 101, you are learning how to take care of problems if and when they arise.

You can learn to understand your back pain better. First you need to learn about areas of the spine that can register pain. Pain is a sensation, just like touch and pressure are sensations. To feel sensations like pain, our body has special receptors, or sensors, that signal our nervous system. There are several structures in the back that have sensors to register pain. Refer to the section below to see which parts of the spine can be a source of back pain.

Making “Sense” of Back Pain . . .

• Muscle: Muscles rarely send pain information, but the tendons on the ends of muscles may register pain.
• Bone: The covering around bones, called the periosteum, has sensors for pain.
• Disc: The outer portion of the annulus can register pain, especially when a crack forms in this area.
• Ligament: These supportive tissues have many pain sensors.
• Nerve: Irritation of the sheath around the spinal nerve can register pain or other symptoms.
• Joint: The enclosure of a joint, called the capsule, is richly supplied with pain sensors.

You can see from this list that back pain can begin in many parts of the spine. The main goal when treating nonspecific back pain is to help you get moving and avoid disabling pain. It's not as important for healthcare providers to figure out exactly which structures in your back are registering pain.

Spine Conditions

In Lesson Five, we introduced you to the changes that sometimes happen in the spine over time. These degenerative changes seem to occur in just about everyone, but only some people end up feeling back pain. Degenerative changes can sometimes lead to certain spine conditions. The conditions listed here represent some of the conditions that spine experts know about.

• Annular tears
• Internal disc disruption
• Herniated disc
• Facet joint arthritis
• Segmental instability
• Spinal stenosis
• Foraminal stenosis

Annular Tears

As you know by now, our intervertebral discs change with age, much like our hair turns gray. Perhaps the earliest stage of degeneration occurs due to tears that occur in the annulus. These tears can result from wear and tear over a period of time. They can also be the result of a sudden injury to the disc, such as a twist, or an increased strain that overpowers the strength of the annulus. These annular tears may cause back pain until they heal with scar tissue.

Internal Disc Disruption

Multiple annular tears can lead to a weakened disc. The disc starts to degenerate and collapse. The vertebrae begin to compress. The collapsing disc can be the source of pain because it has lost the ability to be a shock absorber between the vertebrae. This condition is sometimes referred to as internal disc disruption. This type of problem causes primarily mechanical back pain due to inflammation of the disc and surrounding structures.

Herniated Disc

A disc that has been weakened may rupture, or herniate. If the annulus ruptures, or tears, the material in the nucleus can squeeze out of the disc, or herniate. A disc herniation usually causes neurogenic pain if the disc presses against a spinal nerve. The chemicals released by the disc may also inflame the spinal nerve root, causing pain in the area where the nerve travels down the leg. This type of leg pain is called sciatica.

Even a normal disc can rupture. Heavy, repetitive bending, twisting, and lifting can place too much pressure on the disc, causing the annulus to tear and the nucleus to rupture into the spinal canal.

Facet Joint Arthritis

The facet joints along the back of the spinal column link the vertebrae together. They are not meant to bear much weight. However, if a disc loses its height, the vertebra above the disc begins to press down on the vertebra below. This causes the facet joints to press together. Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the facet joints can develop osteoarthritis as the articular cartilage wears away over time. Extra pressure on the facet joints, such as that caused by a collapsing disc, can speed the degeneration in the facet joints. The swelling and inflammation from an arthritic facet joint can be a source of low back pain.

Segmental Instability

Segmental instability means that the vertebral bones within a spinal segment move more than they should. Instability can develop in the low back if a disc has degenerated. Usually the supporting ligaments around the problem vertebrae have also been stretched over time.

Segmental instability also includes conditions in which a vertebral body begins to slip over the one below it. When a vertebral body slips too far forward, the condition is called spondylolisthesis. Whatever the cause, this extra movement in the bones of the spine can create problems. It can lead to mechanical pain simply because the structures of the spine move around too much and become inflamed and painful. The extra movement can also cause neurogenic pain if the spinal nerves are squeezed as a result of the segmental instability.

Spinal Stenosis

Stenosis means "closing in." Spinal stenosis refers to a condition in which the tissues inside the spinal canal are "closed in," or compressed. The spinal cord ends at L2. Below this level, the spinal canal contains spinal nerves that travel to the pelvis and legs. When stenosis narrows the spinal canal in the low back, the spinal nerves can be squeezed inside the canal.

The pressure from the spinal stenosis can cause problems in the way the nerves work. The resulting problems include pain and numbness in the buttocks and legs and weakness in the muscles served by the nerves. Pressure on the nerves that go to the bladder and rectum is a cause for concern because it can weaken the muscles that control the bladder and bowels.

Foraminal Stenosis

Spinal nerves exit the spinal canal between the vertebrae in a tunnel called the neural foramen. Anything that causes this tunnel to become smaller can squeeze the spinal nerve as it passes through the tunnel. This condition is called foraminal stenosis, meaning that the foramen is narrowed. As the disc collapses and loses height through degeneration, the vertebral body above begins to collapse toward the one below. The opening around the spinal nerve narrows, squeezing the nerve. Arthritis of the facet joints can cause bone spurs to form and point into the foramen, causing further nerve compression and irritation. Foraminal stenosis can cause a combination of mechanical and neurogenic pain.

Raising a Red Flag

Red Flag Circumstances . . .

• Bad trauma
• Mid-back pain
• Changes in bowel or bladder function
• Back pain with no apparent cause
• Back pain in a person under 20 or over 55 years old
• Severe night pain
• Symptoms unaltered by body position
• A previous diagnosis of cancer
• Recent and significant weight loss

Back pain is not a disease, and symptoms of back pain usually go away in a matter of days or weeks. In rare cases, however, back pain can be a signal that something else is going on in the body. You were asked a lot of questions early on about your symptoms. We were checking to make sure there were no "red flags" that would alert us to other possible causes of your pain (such as kidney stones, infection, or cancer). You should also know of other concerning symptoms that require immediate attention.

If these occur, you need to "raise a red flag" for prompt medical attention:

• Cauda equina syndrome
• Worsening leg numbness or weakness
• Worsening pain

Caude Equina Syndrome

The cauda equina, which is Latin for "horse's tail," is the bundle of nerve fibers inside the lower spinal canal that radiate out to the trunk, pelvis, and lower limbs.

Pressure on this bundle of nerves causes distinctive symptoms including low back pain, pain running down the back of both legs, and numbness or tingling between the legs in the area you would contact if you were seated on a saddle. The pressure can disturb function of the bowels and bladder. You need to raise a flag if you feel the need to urinate, but can't, or if you lose bowel or bladder control. Cauda equina syndrome is an emergency. If the pressure isn't relieved, it can lead to permanent paralysis of the bowels and bladder. Doctors usually recommend immediate surgery to remove pressure from the nerves.

Worsening Leg Numbness or Weakness

You should also alert your healthcare provider if you feel leg weakness or numbness that is steadily getting worse. These symptoms may signal increasing pressure on the nerves going to your lower limbs.

Worsening Pain

The third red flag is not as crucial as the previous two. But a flag should be raised if you feel significant back or leg pain that seems only to be getting worse. In this case, it is time to get with your doctor to pursue other tests and treatments.