Older people
It is estimated that 90% of people aged over 65 suffer from back
pain. It was once thought that this was always due to vertebral
arthritis, facetary
arthritis or other organic
disorders of the spinal column caused by wear and tear on the
component structures of the spine. We now know that this is frequently
not the case. Sedentariness and physical inactivity increase the
likelihood of loss of muscle mass, muscular malfunctioning and spasm.
This is good news. Studies have shown that the muscles can be
rehabilitated and trained at any age. This goes for older people,
provided that they follow a suitable training program for their
age and general health and do the exercises best suited to their
particular case.
What is it that increases the risk of back pain in old age?
Of the factors that increase the risk
of back pain occurring or persisting, there are several that
particularly affect older people.
Age increases the risk of back pain in several ways:
Age-related wear and tear on the vertebral structures can increase
the likelihood of organic
disorders of the spinal column, such as vertebral arthritis,
facetary arthritis and spinal stenosis.
Vertebral
arthritis is caused by wear of the vertebral
disc, which becomes thinner so that vertebrae are closer together.
At more advanced ages this causes the person to lose height. This
wear can increase the burden on the vertebra enough to deform it,
producing protrusions known as "osteophytes". However, contrary
to what was once thought, vertebral arthritis is a normal consequence
of the passage of time. Its beginnings are visible in x-rays of
people aged over 30, and it does not normally cause pain. If it
does, this is usually a local pain which appears after intense strain,
or most frequently at the first movement - for instance when you
get up in the morning. It gets better as you move about, and only
in exceptional cases will an osteophyte compress
a nerve and produce more serious symptoms. For more information
about vertebral arthritis, see the relevant
section of this site.
Facetary
arthritis is wear and tear on the back joint of the vertebrae.
There are no nerves on the surface of the joint, and so wearing
does not produce pain. In fact, it is not normally perceptible until
it is advanced enough to affect the bone beneath, and this is not
common. If it does occur, it normally appears in the lower back
and causes pain, sometimes with referred pain in the leg. The pain
is typically more intense when walking than when standing still
and improves or disappears when sitting down. For more information
on facetary arthritis, see the relevant section
of this site.
Spinal stenosis is the narrowing of the bony channel that carries
the marrow and the nerve roots, normally caused by a major deformation
of the facetary joints. With spinal stenosis, you experience irradiated
pain in the legs - normally both, although the pain may appear earlier
or be more intense in one leg - which gets worse the more you walk,
eventually forcing you to stop and sit down. Once you are seated,
it may disappear completely, in which case you can start walking
again until it reappears. If it progresses, spinal stenosis can
cause loss of strength and may even require surgery. For more information
on spinal stenosis, see the relevant section of this site.
However, this same age-related wear and tear does reduce the
risk of other organic
disorders of the spinal column. For example, wear reduces the
volume of the vertebral disc and makes it more fibrous, which reduces
the risk of a herniated
disc. And if you do develop a herniated disc, it is more likely
to cause no problems and may even go unnoticed.
Advancing age also increases the risk of osteoporosis.
Osteoporosis is a reduction of the amount of calcium in the bones,
which makes them more fragile and liable to break. In the case of
the spinal column, osteoporosis can cause spontaneous fracturing
and crushing of a vertebra. Osteoporosis must be very advanced to
cause pain or spontaneous crushing of vertebrae, but if it does
occur it produces a sudden and very severe pain in the middle of
the back (where the crushed vertebra is). It is most frequent in
post-menopausal women, because the sexual hormones augment the deposition
of calcium on the bone and this deposition diminishes after the
menopause. There are now many ways of preventing, diagnosing and
effectively treating osteoporosis. Fractured vertebrae can also
be effectively treated. Osteoporosis is a metabolic disorder and
not a mechanical disorder of
the back and this site does not therefore have a section on
it.
The muscles. Although organic
disorders of the spinal column in older people are most commonly
associated with structural degeneration, in most cases the pain
is due to a mechanical pathology of the back, associated with malfunctioning
of the muscles. There are several factors that make this more common
in older people:
Loss of muscle mass ("muscular atrophy"). With age, all
tissues atrophy more readily, including the muscles. Weakness of
the back or abdominal muscles has been identified as one of the
factors that increase
the risk of new or persisting pain. This is because the lack
of muscle mass increases the likelihood of the muscle becoming overloaded
and going into spasm in response to apparently light burdens. Moreover,
the less muscle mass there is, the less protection there is for
the other structures of the spinal column and the less this is able
to withstand the load. On the other hand, it has been demonstrated
that appropriate exercise can delay, prevent or even reverse muscular
atrophy, even in very old people.
Physical inactivity. In normal conditions the different
muscle groups involved in back function, such as the abdominals
and the paravertebral
musculature, coordinate with one another to o maintain a posture
or maintain balance in movement. This coordination depends on nerve
reflexes, which need to be repeated in order to work properly. Physical
inactivity causes loss of training and deterioration of these reflexes,
so that the muscles contract in the wrong way or at the wrong time
and become susceptible to spasm. However, these reflexes can be
preserved or even recovered by regular physical activity.
Repose.
Repose is bad for the back, and older people are sometimes forced
to take repose for other ailments. Repose accelerates muscular atrophy,
especially in older people, and worsens the muscles loss of training
in the reflexes that enable the various muscle groups to coordinate.
It also aggravates osteoporosis. Repose should be avoided, and where
it is necessary due to other ailments, it should be as brief as
possible.
Can back pain have harmful consequences for older people?
Yes. But due less to the pain itself than to the consequences
of not treating it properly.
If an older person becomes less physically active or takes repose
because of back pain, this will accelerate osteoporosis and muscular
atrophy, and they will find it increasingly difficult to recover
their autonomy of movement. If the situation continues for long
enough, such an older person may eventually find it impossible to
return to normal life.
In cases like this, the loss of autonomy is due less to the pain
itself than to a limitation of physical activity prompted by inappropriate
treatment or by the erroneous belief that because an X-ray or magnetic
resonance has identified an organic
disorder of the spinal column (very common and normally unimportant
in older people), it is best to avoid physical activity and take
repose.
Anyone suffering from back pain can fall into the vicious circle
of pain / inactivity / persistent pain / permanent disability, but
the process is especially rapid in older people, and therefore it
is particularly important to avoid repose or, if repose is strictly
necessary, to keep it to a minimum.
What to do to prevent or treat back pain in older people.
For prevention in older people, the following are both effective
and necessary:
Avoid repose and keep physically active. Older people
should not do more physical activity than their state of health
permits, but they should keep as physically active as possible.
This entails doing aerobic exercises such as swimming, or walking
rather than always taking the car.
Know and observe the rules
of postural hygiene.
Maintain the back muscles. If done correctly and regularly,
some aerobic exercises like swimming may be enough to keep your
back muscles in good shape. If your general state of health prevents
you from doing much aerobic exercise, there are specific exercise
programs for the back muscles that you can follow with a poorer
general state of health. This site contains a section that shows
effective
exercises for this. The programshould be adapted to the condition
of the individual and intensify as he/she improves. Contrary to
what was once thought, scientific studies have demonstrated that
it is never too late if you have the will. There are specific exercises
that can increase muscle mass even in very old people.
When pain appears, it is best not to resign
yourself before you have exhausted all possible avenues of treatment.
Most back pains in older people can be satisfactorily treated, but
they are harder to treat if they go on for a long time. It
is therefore a mistake to believe that pain is normal after a certain
age and will last forever, to resign yourself to bearing it without
doing anything about it. The longer it lasts, the harder it is to
treat. If the pain lasts more than a few days, you should see a
doctor so as to start treating it as soon as possible.
The treatment of common back pain is the same in older people
as in the rest of the population. There is a section of this site
that lists the treatments for back pain, and another that indicates
the common patterns of treatments that have proven effective.
If the pain that an older person suffers is shown to be an organic
disorder of the spinal column, such as facetary
arthritis, spinal stenosis,
or exceptionally, vertebral
arthritis or herniated
disc, the treatments indicated for each disorder should be followed.
These are indicated in the relevant sections of this site.
But before treating for an organic disorder, it must be established
that this is the true cause of the pain. Any X-ray,
scan
or magnetic
resonance of an older person will normally show wear or deformation
of the vertebral
disc, arthritis of the facetary
joints or even narrowing of the channel that carries the marrow,
or spinal
stenosis. But the image alone is not enough; if there are no
symptoms or these do not correspond exactly to what the image shows,
then it is not necessary to apply a treatment specific to that
anatomical disorder.
It is therefore essential to study the characteristics of the
symptoms and determine whether or not these correlate exactly with
the organic disorders shown by the image. This means that the
clinical history and physical examination are even more important
than X-ray or magnetic resonance results. Only if the patient's
symptoms correspond exactly to the image does it make sense to diagnose
and specifically treat such an organic disorder. It would be wrong
to propose surgery on the basis of an image without first
interviewing and examining the patient.
For example, over 30% of the healthy population exhibits protrusions
or herniated discs without ever having felt any pain, discomfort
or even symptoms. One day, such people may suffer common back pain
due to improper functioning of the muscles or to a muscular spasm.
In any case it would be wrong to attribute such symptoms to the
herniated disc, and it would be counter-productive to operate.
Therefore, complementary examinations should only be performed
when there are concrete grounds to support this. If there are
no such grounds, it is pointless to conduct these examinations
given that their results will not modify the treatment. It could
even be counter-productive, since the observation of irrelevant
organic disorders may confuse the diagnosis and lead to incorrect,
unnecessarily aggressive or even counter-productive treatment.
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