Introduction

Anyone who has ever suffered the misery of back pain knows how urgent it is to get relief. Once you are free from the pain, most people will learn as much as they can about their sore back to try to prevent back problems from arising again.
Back pain can vary from person to person, type to type, and region to region, such as the upper, middle and lower back. It can be a dull, constant ache or sudden sharp pain like a dagger that makes it almost too painful to move. It can start quickly if you fall, get a sports injury, or lift something too heavy. Or it might worsen over time, getting progressively worse. One thing is for sure, the pain in a memorable one, and the majority of people will experience it at some point in their lives. Let’s get started with what back pain is and how common it can be.

What is back pain and how common is it?
Back pain can occur for a range of reasons that are either structural, musculoskeletal, nerve based,
or a sign of an underlying disorder. Most back pain is structural or musculoskeletal and
the nerves can be affected by changes in the structure of the spine.
The spine is a complex system of interlocking bones and joints called vertebrae. The spinal
column extends from the base of our skull all the way down to the tailbone at our pelvis, the coccyx. The many vertebrae that make up the spine are labeled in terms of area, and each is given a number so that all doctors know which they are referring to if there are any issues with the back that need to be dealt with.
Starting from the neck, the 4 areas are the:
· Cervical
· Thoracic
· Lumbar and
· Sacral regions.

The cervical region has 7 vertebrae, the thoracic 12, the lumbar 5 and the sacrum 5 bones, all fused together. The coccyx is actually made up of 4 small fused bones.
Most people experience lower back pain. Up to 80% of the population will have it at least once in their lives.
It tends to occur in older people and can increase with age, but of course anyone can get back pain due to injury. The prevalence varies with gender. Women are more likely to have lower back pain, a prolapsed or slipped disc, and sciatica, that is, pain in the sciatic nerves that run from the back down to the lower leg.
The prevalence also varies with race. Black women are two to three times more likely than white women to have part of the lower spine slip out of place.
What are the main causes of back pain? Let’s look at this topic in the next chapter.

What are the main causes of back pain?
Injury is the most common cause of back pain. It is often related to picking up things in such a way as to harm the spine, its nerves, or the muscles around it. For example, many people trying to lift a heavy object with bend over it with their arms straight and try to pull it towards their chest. This strains the muscles, especially in the lower back. Learning how to lift a heavy object properly, as we will discuss later in this guide, can help prevent back injury and a sore back.
Anyone can have back pain, but some things that can increase your risk include:
Poor physical fitness Back pain is more common in people who are not fit. A solid core will strengthen the back as well.

Being overweight
Carrying extra pounds, especially around the middle, can stress the back and cause pain. It is also usually a sign of a flabby core, and flabby muscles are weak and more prone to injury.
Heredity
Some causes of back pain can have a genetic component and run in families.
Various health issues Some types of arthritis and cancer can cause back pain. Osteoporosis, a thinning of the bones, can also result in hairline fractures, bone spurs and other structural changes that can cause back pain.

Smoking tobacco
Smokers with bone injuries heal around twice as slowly as non-smokers. One of the reasons may be that they do not circulate enough nutrients in the body to be able to heal bones and support good back health. As they age, their bones can become so brittle that smoker’s cough can trigger back pain and even injury.

Your job
If you have to lift, push, or pull often in your job, you are more at risk for injury. Many companies offer their workers braces to support the spine, but they need to be worn correctly in order to do any good.
If you sit at a desk all day and do not sit up straight, you may also get back pain. This will most commonly be in the lower part of the back, since this takes so much pressure and weight when you are sitting, but it can also occur in the neck, shoulders and middle of the back as well.
Lower back pain is one of the most common causes of pain, poor quality of life and lost
productivity in the workplace. Chronic back pain can affect every area of your life, including work, sleep, sex, caring for your children, and more.

Fortunately, there are a range of ways to prevent back issues, and to treat them if they do arise. These include natural remedies, medications, and in extreme cases, surgery. The treatments will depend on the cause of the pain.
Sometimes the cause is very obvious, such as an injury. In other cases, the pain is real, but
might require a process of elimination to determine where it is coming from and why.
Doctors try to classify the pain in terms of type and location in order to try to track down the cause and give effective treatment. Let’s look at different kinds of back pain in the next chapter.

Different types of back pain
Back pain will be classified as upper, middle and lower. They will also indicate whether or not the pain is on the left or the right. This can give a clue as to which of the many causes of back pain might be contributing to a patient’s issue.
The causes of back pain can be broadly classified as relating to:
Structure
Muscle pain
Nerve pain
Inflammation, such as is caused by arthritis

Three common classifications of back pain include:
Axial pain
This is also referred to as mechanical pain, and is usually the result of a muscle sprain or strain. It can be dull or sharp.
Referred pain
Referred pain moves around from location to location. It is associated with age-related changes to the spine and can be described as dull and achy.
Radicular pain
This is nerve pain that will often radiate outwards along the path of the affected nerve and can cause the arm or leg to become numb or weak. The pain is described as searing. This pain can result from a number of different causes, including:
· Compression of the nerve
· inflammation
· Injury to a spinal nerve root.
Sciatica (SIGH-attic-ah) is the most common form of radicular pain. The main causes of sciatica are:
· a herniated disc-a disc that has rupture and might be pressing on the nerve
· degenerative disc disease, that is, the results of an aging spine
· spinal stenosis-that is, narrowing of the spine
· spondylolisthesis-one of the vertebrae slips forward onto the bone below it, causing the
nerve to become compressed or pinched
Sciatic pain can generate from the back down to the hip and thigh. In some cases, it might even go as far down as the big toe. This will depend on which vertebrae is affecting it. For example, if the Lumbar 3 (L3) disc is affecting it, the pain will generate down to the buttocks and perhaps the thigh. If the L% is affected, the pain could go all the way down the leg to the big toe.
Therefore, diagnostic imaging will be important to determine the condition of the spine and the placement of the discs.

Certain sciatica symptoms can indicate an emergency and require immediate medical care.
These include, but are not limited to:
· progressive neurological symptoms such as leg weakness or numbness · bladder or bowel dysfunction, that is, the inability to control ones urination or efecation.
These could be signs of cauda equina syndrome, a rare condition marked by extreme pressure and swelling of the nerves at the end of the spinal cord.
Infection or spinal tumors can also cause sciatic pain, so it is important not to suffer in silence thinking it’s a natural part of the aging process.

Lordosis
Another cause of lower back pain is lordosis, an abnormal inward curvature of the spine. It is commonly referred to as a sway back. It can be caused by age, or by poor posture. Treatment usually involves physical therapy, although in severe cases surgery, casting, and/or bracing may be required to restore the proper curve of the spine and ease any pain caused by it.
While it is true that the lower back is the most common area to experience pain, the upper back can be painful for musculoskeletal reasons, often connected with shoulder pain. This part of the spine is not as mobile and flexible as the lower part of the spine, but it can be injured in accidents.

Dowager’s hump
Dowager’s hump, or kyphosis, is an abnormal outward curvature of the thoracic vertebrae of the upper back. Think of it as the opposite of lordosis. It is often the result of osteoporosis, or thinning of the bone. The spine bends and leads to a hump-like appearance. It is often seen in older women, who are much more prone to osteoporosis, hence the name. Osteoporosis is preventable, so the hump can be corrected in many cases.

Scoliosis (SKOL-ee-OH-siss) can affect any part of the back. It causes an abnormal curve of the spine from side to side. People with scoliosis have a spine that can curve from one side or the other, to the point where their spine starts to resemble a letter C or a letter S.
Scoliosis is about two times more common in women than in men. It can start at any age,
though it is usually most common in those over 10. It is hereditary, with it running in families.
The severity of the curve/s and their locations can produce a range of symptoms. Treatment can vary from spinal manipulation and bracing to surgery.

Upper and middle back pain
The 12 thoracic vertebrae that make up the upper and middle back are all very closely
connected with one another, and with your ribs. That being the case, middle and upper back pain can be caused by a number of reasons, including:
Upper and middle back pain may be caused by:
Overuse of muscles
Muscle strain
Injury to the muscles, ligaments, and discs that support the spine
Poor posture
Pressure on the spinal nerves, such as due to a herniated disc.
A fracture of one of the vertebrae.
Osteoarthritis, that is, wear and tear on the spine
The spine shrinks and compresses with age, in part because the discs that cushion cushions the small facet joints in the spine start to break down. Taking care of your cartilage is key to maintaining your discs. Vitamins A, B6, C and E are all important. So too are the minerals copper and zinc. High-quality protein is also essential, as is proper hydration of the body.
Bone broth and leafy greens like spinach and kale can help you keep your spine healthy. Bone broth is easy to make once you know how, and a tasty way to get the most nutrition out of any animal bones in your home, such as the carcass from your rotisserie chicken, or a leg of lamb.
Myofascial pain affects the connective tissue of a muscle or group of muscles and can also
cause back pain in these areas.

When should you consult a doctor, and which doctors treat back pain?
If you experience:
· Shooting or stabbing pains in your back
· Muscle spasms in your back
· Pain that radiates down one or both of your legs
· Limited flexibility or range of motion of the back
· Loss of control of your bladder and bodily functions
It’s time to see a doctor.
If the pain lasts more than 2 weeks, also seek medical attention.
If it is caused by a fall or injury, head to the emergency room for a full check-up. The best
outcomes for any medical condition will usually be when they are caught early.

Doctors who deal with back pain
There are many types of health practitioners that care for patients with spinal conditions. Each has a slightly different focus or specialization. The doctor/s you see will depend on the symptoms and causes of the pain.
Your first step will usually be to see your primary care physician (PCP) or a doctor at your local Emergency Room or Emergency Department (ER or ED). Once they have assessed your condition, they will make recommendations about treatment and might also refer you to one or more other back doctors. These might include:
Chiropractor-they manipulate the spine and soft tissue
Doctor of Osteopathic Medicine (DO)-they focus on the health of the body through the
musculoskeletal system
A spinal specialist, including a surgeon
A physical or occupational therapist to help recovery after an injury
A pain management specialist
Other professionals who can help with back pain relief include:
Neurologists-deal with nerve issues
Rheumatologists-deal with arthritis and other arthritic conditions
Clinical psychologists
CAM practitioners

The goal will be to help you become as pain-free as possible. This might mean medication or surgery in extreme cases, but it might often mean lifestyle changes and education about how to care for your spine better, commonly referred to as spine school. It might also include mind body medicine, in particular for the perception of and natural relief for pain.

A range of CAM practitioners can also contribute to your road to a pain-free back and healthy spine and body. CAM, or Complementary and Alternative Medicine, can be beneficial in a range of ways. As the name suggests, they can be used to complement, that is, be used in addition, to other treatments, with few to no risks of side effects. CAM is becoming increasingly accepted as a means of seeking help for many medical conditions, and most insurance companies have CAM provisions in their policies. We will discuss CAM for a sore back later in this guide.

Then of course, there is you. You know your own back and body best, so you are in the best
position to do what needs to be done to maintain a healthy back and prevent injuries from
happening in the first place if at all possible.
If you do have a sore back, being proactive and following the treatment guidelines given by each practitioner, such as exercises, can help you recover more quickly and hopefully with no lasting damage to your back.
Let’s look in the next chapter at the kind of CAM and other natural treatments that can help a sore back.

Natural treatments to help reduce back pain
There are a number of natural remedies for back pain. The good news is that many of them are free or inexpensive. Their effectiveness will depend on the location and cause of the pain, but these should in general work for the upper, middle and lower back.

Self-care
· resting when your back is sore (but do not rest all the time or you will get stiff and could
do more damage)
· not sitting for too many hours, which puts a lot of pressure on the spine
· gentle, easy stretching
· gently exercising your core muscles-work out your abs
· yoga for stretching, increasing flexibility, and improving core strength-try plank pose
· cold therapy – ice packs or an Icy-hot patch can help
· heat therapy – a warm bath or shower, heating pad or hot water bottle
· hydrotherapy-a warm bath, shower, hot tub or swim in a warm pool
· getting enough sleep-aim for 8 hours each night of high-quality sleep
· sleeping on a bed that gives your back enough support-the mattress should not be too
soft. Look for orthopedic mattresses
· using the right pillows-this will help avoid neck pain
· Medical pillows-some will support the neck. A wedge pillow under your backside when
you are sitting will support the spine and hips. You can also get a specially-shaped
wedge pillow to put between your thighs to help with sciatic pain when you sleep at night
· Making sure you are walking properly in good shoes, avoiding high heels, and taking
care of your feet. Corns, calluses and so on can all lead to sore feet and strange walking
habits
· Having a supportive desk chair-if you’re like most people, spending hours at a desk
every day can take its toll on your back if you are not careful
· Exercising regularly, choosing low impact work outs such as walking, swimming, cycling,
yoga, tai chi, light weights and resistance bands
· Lifting heavy objects, including children and pets, the correct way. (More about this
shortly)
CAM
There are many CAM that have been proven effective for pain relief. Here are a few
suggestions:
Meditation
Meditation allows you to focus your mind, for pain relief and stress relief
Cognitive behavioral therapy (CBT), or ‘talk therapy’
CBT can help with stress and pain relief. It can ease muscle tension as well.
Guided relaxation
You will learn to tense and then relax your muscles, for less tension. Tension and stiffness are major contributors to back pain.

Traditional Chinese Medicine (TCM)
TCM for back pain includes acupuncture-and acupressure. Both stimulate ‘meridians,’ or energy centers in the body, to promote health and healing. Acupuncture uses small thin needles.
Acupressure uses fingers.

Massage
Therapeutic massage therapy, either from your loved one, or a professional massage therapist, can ease pain and stress, and release muscle tension

Aromatherapy
Aromatherapy uses plant extracts known as essential oils for health and healing. Essential oils can be inhaled, added to bath water, or used as part of a therapeutic massage. Choosing oils that promote calm and relaxation, such as lavender, rose and pine, can relieve back pain.

Physical therapy
A sports clinic or physiotherapist can give you gentle manipulation and an exercise program that can help ease your back pain and prevent future injury
Traction/decompression of the spine
There are a number of ways to stretch the spine to take the pressure off compressed discs and nerves
Spine school
Learn more about your posture and body dynamics.

Pain management specialist
A pain management can offer a range of solutions, from natural remedies to medications, to help your back feel better.
If you try all of these self-care and CAM methods and you are still experiencing back pain, it will be time to look at the medications available for lower back pain relief.

Medications for back pain relief
There are a number of effective pain relieving medications, from over the counter to
prescription. They vary in strength, results and potential side effects. Your choice will depend in part on how painful your back is. Most doctors will ask you to rate your pain on a scale from 0 to 10, with 0 being no pain and 10 being extreme pain. Depending on your pain rating and the suspected causes of your back pain, s/he will make a range of suggestions as to which treatment/s will be most effective.
They might recommend:

pain relievers
muscle relaxants
medicines which affect the pain centers of the brain.
The pain relievers can also come in a range of forms, from pills and injections to pain relief
patches.
Whenever taking any pain relief medication, be sure you discuss all potential side effect with the doctor. Take it exactly as prescribed, on the correct schedule, in order to avoid accidental overdose.

The most common medicines for back pain are:
Acetaminophen (Tylenol)
Tylenol is effective, however, it can be dangerous due to the risk of overdose, which can cause severe liver damage. Take exactly as stated and check any other medicines you take, such as cold and flu remedies, because they may have Tylenol in them and cause accidental overdose.

Non-steroidal anti-inflammatory drugs (NSAIDS)
These over the counter medications, such as ibuprofen and naproxen, help stop inflammation, which is one cause of pain. If you’ve ever hit your thumb with a hammer, you will understand what inflammation can do to your back and to your whole body.

Over the counter creams
Topical treatments such as creams can be rubbed into the afflicted area to offer pain relief.
Some contain aspirin, so read the labels carefully if you are allergic. Others contain capsaicin, which comes from peppers, and can cause burns on sensitive skin. Arnica is a natural pain relieving medicine with no strong smell that is useful for pain and bruising.

Over the counter pain relief patches
There is an increasingly wide range of pain relief patches available in the drug store. Popular brands include Icy Hot and Salonpas. They have different active ingredients, including aspirin and capsaicin, so beware of allergies, irritation and itchiness at the site of the patch.

Muscle relaxers
This class of medications can relieve the muscle spasms and soreness that often accompanies back pain. Commonly prescribed drugs include Soma (carisoprodol) and Valium (diazepam).
Both of these can be habit-forming, however, so should be taken on a short-term basis only.

Opioid-based pain relievers
Opiates are potent pain relievers that can be used to treat quickly acute back pain that has not been eased by other treatments or medicines. Drugs in this class include:
· Codeine
· Hydrocodone
· Oxycodone
· Fentanyl.
They can be highly addictive and so should be taken for only a short period of time in as low a dose as possible.

Antidepressants
Antidepressants such as Elavil (amitriptyline) and Cymbalta (duloxetine) can lift depression and in some cases also ease chronic pain. They elevate mood and affect the pain receptor centers of the brain.

Other medicines sometimes used for low back pain are:
Anesthetic injections
There are a number of different injections used to relieve lower back pain through the use of anesthetics. Trigger point injections try to pinpoint the exact spot where the pain is located. Facet joint injections apply anesthetic to the places where one vertebra of the spine connects to another.

Steroid injections
Steroids can relieve inflammation. Epidural injections are injected into the spinal canal to dull the pain in and around the spinal column. As with all medications, steroids can cause side effects, some of which can be serious, including high blood pressure and glaucoma.

Anticonvulsants
These are sometimes used to treat low back pain. Tegretol (carbamazepine), Neurontin
(gabapentin), Dilantin (phenytoin) and Lyrica (pregabalin) are the most commonly used. About 3 out of 10 people gain some relief from gabapentin.

Botox
Botox is commonly used for cosmetic reasons, to smooth and relax muscles and lines in the face. It is now being used for a range of other health purposes, including chronic low back pain.
It can relax the muscles and reduce spasms.
Discuss all possible side effects with your doctor before proceeding with treatment. Let them know what prescription medicines, vitamins and herbal supplements you are taking in order to try to minimize the risk of side effects.
If you have tried a range of medications but are still experiencing chronic pain, it may be time to consider surgery. Let’s look at your options next.

Surgical treatments for back pain
If self-care, natural treatments, over the counter and prescription medications are still not
enough to offer you pain relief, or your back pain has persisted for more than three months, or has a clear structural reason, it might be time to consider your surgical options.
Each type of surgery offers a number of benefits, but also poses certain risks in addition to the usual ones of surgical site infection and complications from anesthesia. Learn as much as you can about the surgery, reasons for it, alternatives, and expected outcomes so you will be fully informed before agreeing to the surgery.

Spinal Fusion
Spinal fusion is the most common surgery for back pain. A surgeon joins one or more vertebrae together in order to restrict the motion between the bones of the spine to prevent wear and tear on the nerves and discs. Depending on which vertebrae are fused, you may experience limited
flexibility and range of motion in that area. Sometimes the discs do not fuse fully. Infection is a definite risk, and those who smoke tobacco are at greater risk of infection and will be slower to heal.

Laminectomy
As the spine ages, it can form lumps, bumps and protrusions called spurs. These can cause
pressure on the nerves, ligaments or discs. During a laminectomy, your surgeon will shave off parts of the bone and/or bony spurs to relieve any pressure that might be causing back pain or leg weakness. The main danger of a laminectomy is that it can weaken the spine further. If this happens, you may need spinal fusion surgery. In some cases, both procedures will be performed at the same time depending on what the surgeon sees when he gets inside.

Foraminotomy
During this surgery, your doctor will cut away some of the bone on the sides of vertebrae in order to widen the space where the nerve roots exit the spine. This can relieve the pressure and pain from spinal stenosis. This can also weaken the spine, in which case spinal fusion surgery would also need to be performed.

Discectomy
The discs of your back are like little cushions separating your vertebrae so they don’t grind
together. Discs serve as shock-absorbers to keep your vertebrae from cracking. They change with age and become thinner, and they can also bulge or slip out of place. This can cause pressure on a spinal nerve. During a discectomy, part or all of the disc will be removed. This procedure might also be done in conjunction with spinal fusion, laminectomy, or foraminotomy depending on your symptoms. Sometimes a prosthetic disc will be inserted to offer cushioning and open up the space between the vertebrae.

Disc Replacement Surgery
Disc replacement surgery involves removing a damaged disc and inserting an artificial one. It is starting to become more popular as an alternative to spinal fusion because it will still allow a good degree of motion and flexibility. The recovery time is also generally shorter. The main risk is infection, rejection of the new disc, or the disc slipping out of place again.

Interlaminar Implant
Another option similar to spinal fusion is implanting a device at the same time as a laminectomy.
The device, which is shaped like the letter U, is inserted between two vertebrae in order to relieve pressure on any nerves that might be pinched. It can help ease the symptoms of spinal stenosis, that is, a narrowing of the spine which might pinch nerves. Compared with fusion, it will help retain mobility and stability in the spine, though a person with an implant may not be able to bend backwards in that area.

Risks of Back Surgery
In addition to the risk of not getting the pain relief hoped for, there are several risks related back surgery. They include:
· Reaction to anesthesia or other drugs
· Bleeding
· Infection
· Blood clots, for instance in the legs or lungs, especially if you are bed-ridden for a long time
· Heart attack
· Stroke
· Disc rupture despite the surgery

Another risk is nerve damage to the spine, which can result in a range of symptoms, including:
· Weakness
· Paralysis
· Chronic pain
· Sexual dysfunction
· Loss of bowel or bladder control (incontinence)
Stay in close contact with your doctor in order to achieve the best outcome possible. Use CAM and medications as needed to gain and maintain a healthy back. One of the best ways to maintain a healthy back is to learn how to lift heavy objects correctly. Let’s look at this topic in the next chapter.

How to lift heavy objects correctly
Lifting heavy objects correctly is the best way to avoid injuring the muscles in your back and/or doing any structural damage.
1-Stand
Stand near the object with your feet shoulder with apart, your dominant foot (such as your right) slightly ahead of the other.
2-Squat
Squat down next to the object, bending at the hips and knees only, keeping the spine straight.
One knee can touch the floor and the other should remain at a ninety-degree angle.
3-Stay Straight
The back should be straight, chest out, shoulders back, not hunched. The head should be up, looking straight ahead.
4-Straighten your legs
Straighten your hips and knees so you are propelling the weight off the floor via their muscles and movement, not the muscles of your back.
5-No side to side
As you raise up off the ground using your legs, keep your back straight. Don’t twist from side to side, as this can injure the muscles in your lower back or compress a nerve.
6-Keep it snug and secure
Hold the load as close to your body as possible. Don’t hunch over it. Lift it up until it is about the level of your waist and hips. NEVER try to lift it higher than the shoulders.
7-Take small steps
Take small steps forward with your load. Don’t try to walk normally, as it can jostle the hips and back and perhaps even make you lose your grip and drop the item.
8-Switch directions carefully
Lead with your hips as you change direction when you are walking with a heavy load, not the feet or the knees.
9-Stay aligned
Keep your shoulders in line with your hips as you move.
10-Set down smoothly

If you have to set down your load on a table or shelf, don’t stretch out your arms. Walk as
closely as possible to the resting place and slide the load on top of it. If you are going to set it down on the floor once more, reverse the lifting process. Squatting with the knees and hips only, keeping the back straight and not twisted, until the item is safely on the ground once more.
Practice this sequence of moves with a small, light-weight box until it feels comfortable and natural, so you will be much less likely to pick up heavy boxes the wrong way because you are not thinking when the time comes.

Anyone who has ever experienced back pain will know how miserable it can be, and to what extent it can ruin your quality of life and prevent you from carrying out your most essential daily activities. Back pain cost estimates put it at $240 BILLION dollars per year in the US, plus lost productivity on the job and at home.

Acute and chronic back pain can impact all aspects of your life negatively, from your
relationships with your children, and your partner, to personal finances, to your job and career prospects. Back pain can affect your sleep patterns, mood and enjoyment of life. Fortunately, a good deal of this can be prevented if you take care of your back so it takes care of you.

Back pain is a fact of life for many, but it doesn’t have to ruin your life. Practice good self-care, use natural remedies over time, and work with your doctor to find a range of effective solutions to help heal your back, and strengthen it for better back health.
To your best back!