Susan, 38, has a high-stress job as a publicist in New York City. She's also predisposed to back problems because she was born with a misalignment in her hips. "I have to sit for long periods of time [at work], so I get really, really stiff," she tells WebMD.
Stephen, 43, of Montreal, is under the gun at work and at home. Seven months ago, he started a new company and got married in the same week. He suffers from many of the ills that afflict people who work at a computer all day, including back, wrist, and arm pain.
Susan and Stephen are members in good standing of an ever-growing club, one you don't want to join -- stressed-out white-collar workers who find that their demanding jobs can become a real pain in the back.
Stress Seeks the Weakest Link
"Back pain is probably the No. 1 reason for visits to doctor's offices, days off work, disability, and litigations," says Gary Starkman, MD, a neurologist in New York City who specializes in pain management.
The pain is usually caused by many different factors working together at once, experts agree. Often, a physical factor, such as lifting or sitting for too long, combines with stress, and the result is a painful back. Where they don't agree, however, is about the degree to which psychological stress on its own can cause back pain.
"Stress can surface anywhere a person has a weak link, whether it be back pain, neck pain, headaches, or whatever," says Rick Delamarter, MD, medical director of the Spine Institute at St. John's Hospital in Santa Monica and associate clinical professor of orthopaedic surgery at the University of California at Los Angeles. "If a person has a propensity for back or neck problems, stress can easily bring them to the surface or exacerbate them."
But according to physical rehabilitation specialist Michael Saffir, MD, chairman of the Connecticut State Medical Society Worker's Compensation Committee, "People can have muscle strain and spasm because of psychological stress alone, but typically that's self-limiting. Take an Advil and do some stretching and it will subside."
John E. Sarno, MD, has a very different opinion.
"Psychological factors, as far as I'm concerned, are far and away the predominant cause of physical symptoms of physical pain in the workplace," says Sarno, professor of clinical rehabilitation medicine and attending physician at the Rusk Institute of Rehabilitation Medicine at New York University School of Medicine and author of the books Healing Back Pain and The Mindbody Prescription.
"All the pressures of life can be considered stressful," he says. "The human psyche is so arranged that in our unconscious minds we do not like stress. As a consequence, we tend to develop a great deal of internal anger to the point of rage. The reason people get physical symptoms [is to be a distraction from this rage]. The physical things the people are doing [like sitting or standing for long periods of time] are not really the cause of the pain. The brain is simply taking advantage of those physical phenomena in order to start the painful process going. The brain produces this pain by slightly reducing the blood flow [to a muscle, nerve, or tendon].
Catherine A. Heaney, PhD, is the co-author of one of the few studies specifically examining the relationship between stress and the risk of developing a back injury. She and her colleagues had 25 men and women fill out personality questionnaires and then lift boxes under stressful (i.e., being yelled at by a supervisor) or nonstressful conditions.
The stress of being yelled at made some of the participants more likely to lift the box in a way that put particular strain on the back. People most vulnerable to reacting this way in the face of stress had introverted and intuitive personalities. This research is published in the December 2000 issue of the journal Spine.
"What our study shows is that psychosocial stress affects the way people move when accomplishing their job tasks," says Heaney, associate professor of public health at Ohio State University in Columbus. "For some people, it increases the loading on the spine, which ultimately is likely to put them at increased risk for low back pain."
What's Eating Your Back?
How do you know whether your back pain is caused by physical or psychological factors? Many experts say they are able to tell the two apart.
"A typical complaint is severe back pain but mostly from Monday to Friday," says Federico P. Girardi, MD. "They get relief during the weekend even though they may be sitting all day watching TV."
That's a sign the primary cause of pain is work stress, says Girardi, an orthopaedic surgeon at the Spine Care Institute of the Hospital for Special Surgery at Weill Medical College of Cornell University in New York City.
Doctors also use physical exams, patient histories, and tools such as X-rays and MRI scans to determine the cause of back pain.
Preventing Back Pain
So where does this all leave the everyday Joe who wants to avoid developing back pain?
First, the basics. You've probably heard this before, but it merits repeating: Anyone who must sit at work for long periods of time should try to keep both feet on the floor, with their knees slightly higher than their hips, says Archie A. Culbreth, DC, director of the Culbreth Chiropractic Clinic in Savannah, Ga., and president of the Georgia Chiropractic Association.
It's OK to occasionally cross your legs or put your feet on a stool or leg rest, he says. Sit firmly against the back of the chair. Chairs with built-in lumbar support, or special supportive cushion, can also be helpful. Get up, move around, and stretch once or twice every hour.
"Sitting puts 11 times more pressure on your lower back than standing, walking, or lying down," he says.
If you have to stand for long periods of time at work, put one foot up on something, like a low stool, and alternate which foot is raised. Change positions often. Avoid bending and twisting at the waist, especially twisting as it can cause damage to the disks in your back. If you must lift heavy items, bend at the knees, keeping your back straight. Keep objects as close to your body as possible while lifting.
Maintaining good health overall helps reduce the risk of developing back pain from stress or any other cause. This means performing regular back and abdominal muscle exercises, not smoking, and keeping your weight within a healthy range. Stretch before any physical activity. As we age, the risk of developing back injuries increases, so men over the age of 45 or 50 need to be especially careful about keeping fit.
"Just getting overweight and out of shape is the No. 1 cause of back symptomatology," says Delamarter. "The majority of back and neck problems that surface when stress brings them on are due to deconditioning. ... It's very unusual to have a patient who does 200 sit-ups a day come into a doctor's office complaining of back pain."
When stress is a major contributing factor to your pain, you need to reduce the tension in your life. Often, stress at work can't be avoided, so you must figure out a way not to let it get the better of you.
"In terms of psychological stress, any type of relaxation therapy that you feel comfortable doing [can be helpful]," says Girardi. "[You can also try] taking time to be outside, listening to music, or doing recreational activities on a regular basis, not just once every few months."
Regular exercise is very important for maintaining back health not only because it keeps your muscles strong and your back well supported, but also because it's a great stress buster.
Stephen says his back pain almost disappears when he runs regularly and lifts weights. "I think the exercise helps because it's good for my back and also because it reduces my stress levels," he says.
Similarly, Susan has found that one of the best ways of dealing with her back pain is to swim three miles a week.
And all you employers out there, heed Heaney's advice about keeping the work place light on stress.
"We need to pay attention to work organization factors that may be causing psychosocial stress, [such as] time pressure, needing to concentrate really intensity for long periods of time, or interpersonal conflict," she says. "What I suggest for any employer is to take a look at what are the stressors in their organization that are causing people psychological distress. If those stressors can be reduced, not only will you have happier employees and better morale, but it is also likely that you will be reducing the risk for low back pain."
Treating Back Pain
What if you're reading this article too late and already have debilitating back pain?
Don't suffer in silence. The sooner your pain can be diagnosed and treated, the more likely treatment is to be effective.
Another important reason to see a doctor for your back pain, especially if you are over 45 years of age, says Saffir, is that in rare cases the pain can be a symptom of a severe condition. These include cancerous tumors of the spine, infections, and progressive inflammatory diseases.
There's a host of people out there who claim they can help you with your back pain, including general practitioners, neurologists, surgeons, chiropractors, and physical therapists. How do you choose what's right for you?
You might want to start with a pain management expert, like Gary Starkman. Although trained in neurology, Starkman's specialty is preventing, diagnosing, and treating pain of all types. Someone like him can help you decide what type of treatment you might need or what other specialists you might want to visit. These decisions often depend on the cause of your pain or the type of injury you have.
Here is just a sample of the options available. A good pain expert will likely use more than one approach:
Watchful waiting: Sometimes mild back pain will go away on its own with no treatment.
Ergonomics: This means thinking about the things you do with your body all day, such as sitting or standing too much and lifting inappropriately. All the things people should do to prevent back pain go double for those already experiencing pain.
Psychotherapy: If your pain is stress-related, a therapist can help you identify and cope with it. Sarno believes that developing a deep understanding of the psychological causes of your back pain, as well as why the brain translates stress into pain, can go a long way toward relieving your discomfort.
Physical therapy: This includes doing exercises and stretching that help prevent and treat back pain. These can be done with the help of a physical therapist or at home, after you have been taught how to do them properly. Continuing to stretch and exercise to keep your back in shape even after you feel better can help prevent another back injury.
Massage: Doesn't the word alone make you feel better already? A recent study showed it to be one of the most effective treatments for chronic low back pain.
Chiropractic adjustments: Chiropractors are adamant that the spine adjustments they perform are the single best treatment for back pain. "[Spinal manipulation], or using the hands to apply force to the back or adjust the spine, is helpful in the first month of low back symptoms. It's a proven treatment that works," says Culbreth.
Drug therapy: This can range from occasionally taking an Advil or aspirin to having muscle relaxants injected directly into sore muscles or having a pump continuously deliver painkilling medication to your spine.
Surgery: Even orthopaedic surgeons Girardi and Delamarter say surgery should be used only as a last resort. It is not always effective and, if used inappropriately, can make problems worse.