Back pain is a widely prevalent malady that is known to affect individuals the world over. It has no respect for age, gender or socio-economic status. At any point of time 15% of the world’s population can be afflicted with back pain. In fact, 65 to 80 % of people complain of at least one episode of back pain in their lifetime. Moreover, the recurrence rate is high and 50% have a recurrence of back pain within 1 year of a previous episode.
The most common cause for chronic back pain is due to degenerative changes in the spine due to aging. But the incidence of back pain in the younger population including adolescents and teenagers is also on the rise. People in their 30’s are presenting with back pain and even prolapsed intervertebral disc (slipped disc) manifesting as back pain and sciatica (pain going down the leg). Since degenerative changes in the spine are not a likely cause for back pain in young people, what could be the possible reason for the rising incidence of back pain in this population? Can genetics and lifestyle causes be a contributing factor?
Manchikanti in an article, “Epidemiology of Back Pain” published 20 years ago (Pain Physician 2000), mentioned age, genetics, smoking, obesity, prior history of low back pain, job dissatisfaction, heavy lifting, static work postures, osteoporosis, vibration and psychosocial factors as possible risk factors for developing back pain. Ferriera et al in an attempt to analyse genetic and environmental factors published a study in European Journal of Pain in 2013 titled, “Nature or Nurture in Low Back Pain: Results of a Systematic Review of Twin Studies.” In this study, he analysed 27 longitudinal and cross-sectional studies involving twins. Twins were studied as that could assess the genetic factor in the cause of back pain. These authors found that genetics contributed to 21 to 67% of back pain. It accounted more for chronic and disabling back pain as compared to recent onset and less disabling back pain. Surprisingly, the peak incidence of 67% was found to occur in adults aged 30 years.
The lifestyle or environmental factors that these authors found that predisposed to back pain included smoking, obesity, physical function as measured by grip strength, physical workload and co-existing illnesses such as hypertension, coronary heart disease, bronchial asthma, osteoarthritis, diabetes, headache and chronic fatigue syndrome. Self-assessment of poor health was also associated with back pain. A higher socio-economic status was found not to be protective for low back pain and affluent people are not in any way immune from back pain.
The environmental factors that were not associated with back pain included alcohol consumption, higher physical activity and decline in cognitive function. While depression was not linked to the prevalence of back pain it was associated with the disability associated with low back pain.
Genetic factors cannot be changed. But environmental and lifestyle factors can be nurtured and changed.
We are all aware that changes in lifestyle behaviour is well accepted in addressing non-communicable diseases like diabetes, stroke, obesity and heart disease. Can positive changes in lifestyle decrease or even prevent the occurrence of back ache?
Some of the negative lifestyle behaviour that are known to adversely impact the spine are lack of physical activity, lack of exercise, obesity, smoking, poor nutrition, insomnia and stress.
Let us discuss some of the lifestyle factors and see how it impacts the spine.
Exercise
The beneficial effects of exercise on the body can be traced back to India. Sushruta (600 BCE), an ancient Indian physician and surgeon, ‘prescribed’ daily exercise to his patients. Charaka (3 BCE), one of the principal contributors of Ayurveda, also advocated daily exercise. Hippocrates (460-370 BCE), the Father of Medicine, too advised exercises for healing of sprained ligaments.
A systematic review and meta-analysis done by Steffans et al (JAMA Int Med 2016) showed that exercise alone or in combination with patient education can prevent low back pain. In yet another study that evaluated interventions done in the workplace to prevent back pain found that only exercise, either alone or done in combination with patient education, was effective in preventing back pain (Sowah et al, J of Safety Research 2018). Both these studies stress the importance of exercise and patient education in preventing back pain. More often than not, doctors and physiotherapists enumerate a list of exercises that need to be done, but how often do they explain to their patients the rationale behind the exercises? The type of exercises that are beneficial include core exercises, spine range of motion exercises, resistance training, aerobics and stretching exercises. Ideally 5 to 17 minutes of exercise doses and 6 minutes of training per working day has been found to be effective.
How does exercise prevent back pain?
- Exercise strengthens & conditions the muscles related to the spine. Bed rest & lack of exercise de-conditions & weakens these muscles
- It increases trunk flexibility
- It improves blood supply to the spinal muscles, joints & intervertebral discs
- Has a psychological effect too and can improve mood & decrease perception to pain. It does this by releasing neurochemicals like serotonin which activates the descending inhibitory pain pathway and decrease the perception of pain.
Physical activity
Sedentary lifestyle has been found to be a risk factor for non-communicable diseases like diabetes, hypertension, stroke & some cancers. It has also been found to be a risk factor for musculoskeletal diseases like back pain. Yi Chun Chou found that low back pain was linked to less physical activity and increase in sitting hours (J Rehab Med 2013). Low back pain patients report doing physically demanding work with no physical activity during their leisure time. People doing less physical activity also tend to sit for longer hours.
Lack of physical activity can affect mental health also. People with chronic back ache have a condition called ‘kinesiophobia’, which is fear of movement. This could either be a genuine fear or it could be a pain avoidance behavior where movement is used as an excuse to avoid doing activities such as exercise, walks or even self-care activities. Physical activity & exercise have been recommended for people with mental health problems. Those who do more physical activity & exercise report better mental health (anxiety & depression) than those who do not & have a sedentary lifestyle. Physical activity can actually offset the adverse effects that pain has on mental health and reduce pain.
Thus, it is recommended that for people with chronic back pain, staying active, doing regular exercise and self-care activities to stay functional are beneficial. A sedentary lifestyle can be harmful and can make a person vulnerable to back pain.
Smoking
Smoking has an adverse effect on the musculoskeletal system and can aggravate the progression of back pain. There is a link between tobacco use and decrease in bone density or osteoporosis. It can also decrease the threshold of a person to pain. Quitting smoking improves musculoskeletal health & exercise endurance by improving perfusion of blood to muscle & bones and preserving bone density.
Obesity
Obesity and overweight could increase the mechanical load on the spine by causing a higher compressive force and increased shear on the lumbar spine structures during various activities. Abdominal obesity, in particular, is associated with low back pain.
Posture
The link between posture & LBP not clear. Prolonged work in non-neutral postures, heavy physical loading, bending and twisting can predispose to disc degeneration. Also, prolonged sitting position can decrease the normal lumbar curvature, increase pressure on the intervertebral disc and increase low back muscle activity. All these factors can predispose to back pain.
Sleep
Sleep deprivation can impact physical health & cognitive function, which is the ability to think, reason, remember and pay attention. There is also a relation between poor sleep & back pain. 50% of patients with back pain report insomnia. Besides lowering pain threshold & pain tolerance, it can cause fatigue, mood & cognitive disturbance, anxiety & depression, all of which can worsen back pain
Osteoporosis
There is an independent positive association between osteoporosis and back pain. Interestingly, males are more prone to osteoporosis induced back pain. How does osteoporosis cause back pain? It causes low bone mass & micro-architectural deterioration in bone tissues leading to bone fragility & micro-fractures. Also, insufficient central axial skeletal support leads to imbalance of muscle, ligaments & tendons of the spine and this could lead to structural changes in the spine curvature, biomechanics of the spine and even cause instability of the spine.
Mental health
Physical wellbeing of an individual is closely linked to mental wellbeing. People with musculoskeletal dysfunction can have mental disorders like anxiety, depression and stress. Conversely, people with mental health issues can have musculoskeletal dysfunction. Mental disturbances such as anxiety, depression and stress can also affect the lifestyle of a person. Such people are prone to poor food habits, overeating, insomnia, smoking and less physical activity. This, in turn, can predispose to back pain. Stressors that contribute to back pain may be occupational or domestic. Occupation or work-related stressors can be due to the physical environment (noise, temperature, vibration etc.), safety at the workplace, poor ergonomics, commuting to and from the workplace and the interface between job and family/social life. Domestic stressors include family relationships, coping with household work, lack of relaxation etc. Gender can also influence back pain caused by stress and it has been found that stress induced back pain is more common in female dominated professions. It has been found that nurses, flight attendants, teachers and female administrators are more prone to stress induced back pain.
In summary, lifestyle practices can independently or in combination cause back pain and there is sufficient evidence for pain specialists to consider incorporating lifestyle behaviour changes to prevent & treat back pain. But it is not a magic bullet. Unlike conventional pain interventions, the benefits of lifestyle behaviour change on back pain may take weeks or months to be effective. However, it is more likely to be long lasting & sustained.
Positive lifestyle behavior includes the following:
- Physical activity & exercise
- Adequate sleep
- Good ergonomics and correct posture
- Prevent & treat osteoporosis
- Reduce body weight
- Refrain from smoking
- Stress management
We cannot prevent Nature from taking its course as genes were something we were born with and it cannot be changed. But we can Nurture our backs by appropriate lifestyle habits and prevent unnecessary physical suffering and mental distress.