The gentleman was 76 years of age and looked upon himself as a very healthy individual.  He took no medications on a regular basis and had not seen a physician for health concerns for 3 years.  He came to the clinic because of severe low back pain.  He described his daily routine as getting up in the early morning hours and moving feed to his cattle.  Sometimes, he would have to carry a bucket of grain weighing 40-50 lbs and sometimes he would carry one in each arm.  He had had a busy month and during that time his back pain had faded in.  He didn’t think there was any one single event that started the problem it just seemed to get worse each day as he got out of bed.  The pain felt better if he sat in his recliner with a heating pad on his back but he hadn’t taken any medications (didn’t believe in them!!).  He said that he just needed to know what was wrong with his back so he could get it fixed.  X-rays were taken and showed no abnormality.  The pain didn’t radiate into either leg but it got significantly worse when he tried to stand up or walk about.  The pain was especially bad after he carried multiple buckets of grain to the livestock.   His weight was not excessive and he had excellent posture.  He never reported having had arthritis problems previously and had no injuries to start the problem.

     I told him that he had a strain of the muscles in his back but that there was no abnormality that required a surgical intervention.  He was told that the best treatment for this was rest, local application of heat such as he was already doing and slowly working back into his routines.  It was suggested that he use pain medications both to speed his recovery and to alleviate the pain that he had.  Lastly, he was told that it could take between one and five weeks to get good relief of symptoms and return to normal function.

     As you might imagine this was not a very satisfying answer for him.  He wanted something fixed NOW.  He said that he was sure there must be something wrong with his kidneys or maybe he had a cancer or some such thing.  Several more tests were done and he was told that there was no evidence of a cancer and there was no evidence of a kidney problem.

     I then sat down with him and explained that there are basically four reasons why backs hurt.  The first and most common reason is muscle strain such as he had.  Imagine that you take your left arm and pick up something heavy and hold it out in front of you.  Depending on how heavy the object is you may be able to hold it for varying lengths of time.  But if you continue to hold it long enough, your arm will begin to hurt.  For illustration purposes, I had him do this with a heavy book that I had in the clinic letting him hold the book out in front of him while we were talking.  Pretty soon his arm began to waiver slightly and I asked if it was hurting to which he replied yes.  I asked if he thought his arm was sick or diseased or needed surgery and he said no.  I asked then why is his arm hurting.  With an instant reply, he said it was hurting because he was straining it and I said “DING!”; right answer.  I then asked him what the difference between his arm and his back was.  He replied that when he put the book down, his arm quite hurting but his back was still hurting.  I asked him what would happen if he held the book out in front of him for a day, and he replied it would it get sore and keep hurting probably.  I said. “DING!!”, right answer again.

     Muscles begin to hurt when you pull on them harder than what they are going to put up with.  The back muscles are partially voluntary but for the most part but really not thought about.  One stands up the way they will but nobody constantly thinks about pulling on their back muscles to keep themselves erect.  Our natural tendency when a muscle begins to hurt is to hold it steady and splint it so the hurting will stop.  But in the case of backaches that is what is making the back hurt to begin with; so splinting your back only makes the pain worse but the person  with the back ache doesn’t know that so they keep on splinting and keep on hurting.

     So I explained to this gentleman that in order to get the back to stop splinting and pulling, he needed to stop the pain.  Then the muscles could relax which would relieve more pain letting the muscles relax some more.  I explained to him that, therefore, pain medications for backache are not only a relief of the pain but an essential part of the cure.

     The use of a heating pad is an individual consideration.  Some people feel that putting an ice pack on the back muscles works better for them and if that makes it feel better that is what they should do.  For most people, warmth makes muscles relax and therefore hurt less.  In my experience, cold makes muscles tighten up and therefore hurt more but it is a personal choice.

     The third component of treating low back pain secondary to muscle strain is to rest the muscles.  Not complete bed rest that leads to deconditioning, rather the person should be up and about some each day but avoid the activity that lead to the back strain to begin with.

     Many times I have patients ask for a muscle relaxant.  I hate to burst their bubble but, in fact, there is no such thing.  The first medication that was touted as a good muscle relaxant was Valium(diazepam) and a number of others such as Flexeril(cyclobenzaprine) have been used since then.  In fact, the real effect of these medications is to act as sedative and the sleepiness side effect that comes from these medications may make the whole person relax some but there is no such thing as a selective muscle relaxant in the absence of sedation.  So muscle relaxants are perhaps useful for people who are unusually tense, anxious and sleep deprived.  In that context, they can be helpful by re-establishing a more physiologic sleep pattern.

     Next weeks’ column will deal with other more serious and difficult to treat low back pain problems.  On Saturday morning, January 31st, 2004, there will be a presentation at the Medicine Rock Café in Gettysburg on “Low Back Pain and How To Diagnose and Treat It”.