FAQ Category: Lumbar Spine

Management of chronic pain is recognized as a challenging and often complex problem that requires careful management to be effective. Starting with an osteopath is a good idea to help get things lined up and restore a more normal musculoskeletal frame.

Branching out to other disciplines is often helpful. There are many health care professionals who work together smoothing the way to recovery for pain patients. Medical doctors (including osteopaths), chiropractors, physical and occupational therapists, and pharmacists are often among the core team members.

Alternative practitioners can also provide effective care. This can include massage therapists, acupuncturists, craniosacral practitioners, naturopathic physicians, Reiki therapists, and so on. If your osteopathic physician has helped you, trust her professional judgment and try this next step. It may be that your system is ready now to handle other types of care. It may help if you ask your osteopath to explain her rationale (thinking) in referring you for other services. She may have a plan of care that would make perfect sense to you.

Cauda equina syndrome is a serious neurologic condition. There is a sudden loss of function of the nerve roots of the spinal canal below the conus (end of the spinal cord). The spinal cord travels down the spine inside the spinal canal. The canal is a circular opening formed by the vertebral bodies.

In most people, the spinal cord ends around the first or second lumbar vertebra. After that, there is a mass of nerves called the cauda equina. Translated literally, this means horse tail. As part of the cauda equina, nerve roots branch off from the spinal cord from L1-5 and S1-5.

Anything that presses on the cauda equina can disturb the nerves. The most common problem leading to a cauda equina lesion is a central disc prolapse. This means the disc located between two vertebrae (in this case between L4 and L5) pushes straight back and presses on the spinal cord.

Weakness of the legs from pressure on the nerve roots supplying the leg muscles is a common first sign of a cauda equina syndrome. If the compressive force on the spinal cord or cauda equina is severe enough, the person can even become paralyzed.

Another sign of cauda equina compression is poor bladder function. The patient may not feel the stream of urine when going to the bathroom. There may be decreased rectal tone, saddle anesthesia, and sexual dysfunction. Saddle anesthesia refers to numbness in the area of the groin that would be in contact with a saddle. This is a sign of serious nerve impairment.

Some patients with a cauda equina lesion have no pain and can still walk. Others are in a wheelchair and cannot function. The diagnosis is usually made based on clinical presentation and confirmed by an MRI or CT scan. Immediate surgery to decompress the disc is usually advised. Whether or not the patient can have a decompressive discectomy (disc removal) depends on the underlying cause of the compression and the patient’s general health.

A bulging disc in the lumbar spine can respond to conservative care. Proper positioning, specific exercises, and avoiding certain movements can help reduce pressure from the disc on the spinal nerve roots.

A more serious problem occurs when the disc protrudes and presses on the cauda equina. Cauda equina means horse tail. It was given that name because nerve roots that form the tail branch off from the spinal cord from L1-5 and S1-5. Located at the bottom of the spinal cord, these nerve roots are bunched together and look like a horse’s tail.

Cauda equina syndrome is a serious neurologic condition. There is a sudden loss of function of the nerve roots. The patient experiences numbness, tingling, weakness, and even paralysis. There may be significant bowel and bladder dysfunction. If left unchanged or untreated, permanent damage can occur.

MRIs can be done during pregnancy. The radiologist reviews the case and evaluates the risk-benefit ratio. Immediate surgery is usually recommended for this problem. The risk of permanent paralysis with this kind of problem is often too great to treat progressive cauda equina in any other way.

Surgery to remove the bulging disc (discectomy is usually done. There are published cases of pregnancy women having lumbar MRIs and discectomy for this problem. No harm was done to the baby with the MRI or the surgery and a normal birth has been reported.

In a report offered at the North American Spine Society’s annual conference this year, physicians were reminded not to rely on their own memory by asking favorite questions when interviewing patients to assess the patient’s psychologic state. There are better, more accurate tools available to do this. One of those tools is a psychologic questionnaire called the Distress Risk Assessment Method (DRAM).

According to a recent study, experienced surgeons aren’t any better than less experienced physicians in assessing patients’ psychologic stress. This type of evaluation is important because past research has shown there is a significant impact of a patient’s psychologic health on their response to treatment for spine-related back pain.

To come to this conclusion, eight spine doctors (equal numbers of surgeons and physiatrists) interviewed 50 patients each (for a total of 200 patients in the study). The doctor-patient interview was meant to do a psychologic assessment and determine who needed psychologic help. Each of the 200 patients also filled out the DRAM questionnaire. The results of these two measures were compared.

Categories used to classify patients’ psychologic risk included normal (N), at-risk(AR),distressed depressive (DD), and distressed somatic (DS). It turned out that nonoperative spine specialists (those who offer conservative, nonsurgical care) were much better at recognizing when patients had significant levels of psychologic stress to be at risk for a
poor treatment result.

Surgeons relying on their own instincts were less likely to detect patients who were at-risk or distressed. It was suggested that physicians use the DRAM for better results in this area of assessment. The DRAM has been validated by research studies. This means it is both reliable and effective in measuring psychologic distress in spine patients.

This study mostly shows that when it comes to recognizing the psychologic components of back pain, many patients are underdiagnosed. The fact that your doctor could see the possibility of an underlying psychologic state affecting your overall health suggests he is up to date in this area. It can’t hurt to follow his advice. After consulting with a mental health care specialist, you may feel differently about this issue.

The back, the spinal cord and all the discs that support it, takes on a tremendous load every day. Many people do injure their back, sometimes in the seemingly most innocent and unexpected way. However, you don’t always have to injure your back to have pain. Sometimes, the discs begin to degenerate for other reasons, such as arthritis.

To say that the discs are dying does sound shocking. What actually happens is the discs can begin to degenerate and then the can’t support the weight of the body and help you move as your back should let you.

In order to see if your father has degenerating discs, the best test is a magnetic resonance imaging (MRI), which allows doctors to see the color of the center, or nuclei, of the disc. If the center is white, the disc is healthy. If it’s gray, it is moderately degenerating, and if it’s black, it’s severely degenerated.

It might. Being rested before major surgery isn’t a bad idea. But it may depend on the type of work you do and whether it is physical and/or emotionally stressful. A little bit of stress can be beneficial. But too much stress puts a strain on the immune system (and other systems).

Extended periods of time off work before having a total disc replacement has been shown to be harmful. Patients who are off work on sick leave or disability tend to have worse outcomes after disc replacement compared to those who are still working when the surgery is done.

You may want to ask your surgeon this question. There are other factors that he or she will take into consideration such as general health, lab values, and vital signs.

Artificial disc replacement (ADR) is a device or implant used to replace a diseased or damaged intervertebral disc. After removing what’s left of the worn out disc, the ADR is inserted in the space between two lumbar vertebrae.

The goal is to replace the diseased or damaged disc while keeping your normal spinal motion. Artificial disc surgery is relatively new in the United States but has been used in Europe for many years. In the U.S., the first artificial disc surgery in the United States was done in October 2001.

As with any new device, surgeons don’t just use it with anyone and everyone to see how it works. They must follow strict guidelines provided by the implant manufacturer and the results of published studies. You may be a good candidate for a lumbar artificial disc replacement if you have chronic pain and disability from lumbar disc degeneration despite nonoperative treatment for at least six months.

Finding the ideal patient for total disc replacement (TDR) surgery helps ensure successful results. Identifying subgroups of patients who should not have TDR surgery is also important. As the authors of one study sum it up so nicely, Patient selection is the primary key to achieving a favorable outcome.

The main use of TDRs is Reports of short- and medium-term results are now available. The data from these studies has helped shape selection criteria for this procedure. As you discovered, age restrictions (younger than 65 for most surgeons, younger than 60 for more experienced surgeons) apply. Body mass index (BMI) indicating being overweight or obese is another defining factor.

Anyone with degenerative changes of the facet (spinal) joints is also excluded. Without good joint health and alignment, normal motion is not available and an artificial disc won’t change that. And bone loss from osteoporosis is also a risk factor for poor results. The disc device sinks down into the bone and/or there is a risk of bone fracture around the implant.

Being retired or off work is another risk factor. Some new findings show that the longer a person is off work for sick leave or disability, the worse their final outcomes. Although being retired hasn’t been examined, it may be considered a risk on the basis of the research that showed off-work status was linked with worse outcomes.

So, even though you weren’t selected for this procedure, your surgeon had your best interests in mind. Patients who don’t qualify for this procedure are more likely to have problems and complications that are best avoided.

Fear of movement and fear of re-injury are common after traumatic injuries and especially in people with low back pain. The knowledge and fear that certain movements will cause pain result in avoiding movement. Eventually, this fear-avoidance behavior can lead to loss of function and disability.

Studies show that pain-related fear affects how patients respond to their pain. Pain catastrophizing is a part of the problem. People who catastrophize tend to do three things. They think about their pain and can’t stop thinking about how much it hurts. They blow their pain out of proportion and are afraid that there might be something really serious wrong. And they feel helpless to change their pain, believing that there is nothing they can do to reduce their pain.

You may be experiencing some of these responses when you reach the limits of your pain free motion and become aware (and possibly fearful) that if you go any further, something is going to hurt. It is possible to work through this response. It takes time and may require the supervision of a health care professional such as a physical therapist.

The therapist will help you learn how to do graded exercise. Together, you would find out how much exercise you can do before your pain stops you. This is referred to as exercising to pain tolerance. You start at that level of exercise or activity. The therapist guides you in building tolerance by slowly increasing duration, intensity, and frequency of the exercise or activity.

Another approach called graded exposure starts by looking at which activities you are fearful of (e.g., lifting, carrying, twisting, bending). Each of those activities is then practiced with supervision or guidance from your therapist. You should start at a level that feels safe to you. Rate your fear before and after each activity. As the fear goes down, the frequency, intensity, and duration of the activity is increased. Then you can start doing the same things at home on your own.

The final step is to start including activities and movements that you’ll need for horseback riding. If you let your therapist know your goal of getting back in the saddle, he or she can help tailor your exercise and home program to reach that goal.

New information on the role of psychological factors in chronic low back pain (LBP) is being reported and studied. One of the latest models for managing LBP is called the Fear-Avoidance Model (FAM). The idea is that fear of movement and fear of re-injury result in avoiding movement and eventually lead to loss of function and disability.

Studies show support for this idea. Pain-related fear affects how patients respond to their pain. Pain catastrophizing is a part of the problem. People who catastrophize tend to do three things. They think about their pain and can’t stop thinking about how much it hurts. They blow their pain out of proportion and are afraid that there might be something really serious wrong. And they feel helpless to change their pain, believing that there is nothing they can do to reduce their pain.

Two methods to reduce fear-avoidance behavior are being studied: graded exercise or graded exposure. Graded exercise starts by finding out how much exercise each patient can do before their pain stops them. This is referred to as exercising to pain tolerance. Then the patient is enrolled in a program that starts with that level of exercise or activity. The therapist guides the patient in building tolerance by slowly increasing duration, intensity, and frequency of the exercise or activity.

The graded exposure approach starts by looking at which activities patients are fearful of (e.g., lifting, carrying, twisting, bending). Each of those activities is then practiced under the supervision or guidance of the physical therapist. Patients start at a level that feels safe to them. They rate their fear before and after each activity. As their fear goes down, the frequency, intensity, and duration of the activity is increased. Then they are encouraged to start doing the same things at home on their own.

There is some evidence that this type of approach is beneficial for patients with low back pain. It may help keep you from progressing to a point that you have chronic low back pain. Or if you’ve had pain for more than six months, it can help you get back on track to increase function and reduce disability despite your pain.

Some patients just go too fast with this program. They may increase the frequency, intensity, or duration of an activity because it doesn’t hurt. But later they experience an increase in painful symptoms. At that point, the therapist will help them back off and start again more slowly. That may be your situation. You may want to work with your therapist a little longer before giving up on this approach. It can be very successful in restoring more independent function over time.

Thoracolumbar burst fractures occur in the spine where the end of the 12 thoracic vertebrae meet the start of the five lumbar vertebrae. A high-energy load through the spine causes the vertebra to break or shatter into many tiny pieces. That’s why they call them burst fractures.

Burst fractures are most often caused by car accidents or by falls. The danger of these fractures is that the bone fragments can shift and press into the spinal cord or spinal nerve roots causing temporary and even permanent neurologic damage.

Surgery isn’t always needed for this type of injury. Surgeons can use a special classification system called the Load Sharing Classification to determine if surgery is needed and what kind of surgical approach to take. Studies have shown that even when the fracture is unstable and the patient has neurologic symptoms, conservative care can still be very successful.

Using the Load Sharing Classification, the surgeon can predict which patients will have a good outcome. A program of bed rest with proper positioning and/or traction to realign the vertebrae is the first step. The patient’s pain dictates how long bed rest must be followed.

When the surgeon permits upright posture and walking, a supportive brace is worn. The patient can expect at least a three-month period of time using the brace. The goal is to maintain good spinal position during the healing process.

Vertebral fractures of this type often affect the front of the vertebral body. Collapse of this portion of the spine results in a kyphotic deformity. Kyphosis means the spine curves forward. If the treatment is not successful in maintaining spinal alignment during and after healing, the patient can become bent over as a result. This effect is referred to as loss of kyphosis correction.

X-rays may be used to monitor the position of the spine and observe for any signs that there is a spinal deformity developing. According to one large study recently published, the recovery rate for patients following this treatment protocol is very high (93 per cent).

The Load Sharing score taken from X-rays and CT scans right after the injury occurred did correlate with the angle of kyphosis (correction maintenance or loss) at the end of the study. Patients with good correction of the kyphosis deformity had less severe pain and better overall function (including return to work).

The results of this large study indicate that conservative care for thoracolumbar burst fractures is both safe and effective.

That’s a good question and one that researchers have not been able to answer despite many studies on low back pain. It’s widely accepted that many people with degenerative changes in the spine can have no symptoms at all — while others with no visible changes on X-ray and CT scans have severe, chronic low back pain.

Scientists are actively looking for the source of the pain. Injecting a numbing and antiinflammatory drug into or around the facet (spinal) joint gives pain relief to enough people to consider this area as a potential source of back pain.

But a recent study comparing CT scans of the lumbar spine in patients with and without low back pain has brought this assumption back into question. There were many people with degenerative changes of the lumbar spine (and especially the facet joint) that did not have any low back pain.

In fact, by age 40, one-fourth of all the adults tested had signs of degenerative changes. And by age 70, the majority of people had significant signs of bone spurs, cartilage thinning or thickening, and hardening of the joint capsule. These changes were more common among women of all ages but the incidence of back pain wasn’t any greater.

So, we may be back to the drawing board on this one. Future studies will focus on finding both the source and the cause of low back pain. Variables such as age, gender, general health, body weight, and genetics may play a role either individually or when combined together. There’s some support for the idea that arthritis is associated with risks for the development of other conditions to develop such as heart disease, high blood pressure, and ulcers. It remains to be seen what is the exact connection there.

Over the years, there’s been a lot of debate about the source of pain felt in the sacroiliac joint (SIJ). Is it coming from the joint itself? From outside the joint? Or both? Injecting a numbing and antiinflammatory (steroid) agent
into the SI joint has convinced scientists that pain can come from the joint. Relief of pain after injection is proof of that.

But what about the many patients whose pain isn’t relieved by an injection into the SIJ? Would injecting this same pain reliever and steroid outside (but near) the joint help? In a recent study, surgeons split the total usual dose of medication in half. They injected half into the SIJ and the other half under the posterior sacroiliac ligaments at the
S1-3 level.

They found that injecting a numbing agent and steroid into the SI joint and also around the posterior interosseous ligament was a successful treatment for patients with chronic SI pain. The results support and confirm the findings of several other studies that reported sacroiliac joint pain can come from outside the joint. The number of patients who experienced pain relief with the dual blocks increased by 47 per cent over just the single injection.

If you got any amount of pain relief with the first injection, it’s a good indication that a second injection will help. Some studies have also shown that maximum pain relief doesn’t always occur right away. Some patients continue to improve over time. The positive results they experienced at the end of three weeks after the injection are even better three months later. This may be in keeping with the saying that time heals all. The exact neural mechanism isn’t known yet but research continues to help define what treatment works best for each type of patient.

Many studies have been done on the use of acupuncture for low back pain. A recent review of all the latest studies found no less than 1,600 new studies just in the last two years. But not all studies are equal in design and quality. So coming to any firm conclusions can be difficult.

Among the studies considered, all types of treatment comparisons were made. For example, acupuncture was compared with sham treatment. Acupuncture was compared with no treatment. Some looked at the results of acupuncture compared to traditional methods. Other studies compared acupuncture alone versus acupuncture combined with traditional (conventional) therapy.

In each study, the treatment procedures were checked for adequacy. In layman’s terms we would say the technique used had to be up to snuff. In other words, the protocol used had to match what was published in textbooks, taught in up-to-date programs, and practiced in advanced clinical settings. Details of acupuncture treatment such as points selected for needling, number of points needled, length of time needles were kept in, and number of sessions were evaluated.

The results were measured in different ways as well. But the most typical outcome measures were pain intensity, function, disability, general health status, and return to work (yes versus no, length of time off work). There was moderate evidence that acupuncture was better than no treatment. At the same time, sham acupuncture worked just as well as true acupuncture. Sham acupuncture means the needles were not placed at true acupuncture points, they were only inserted a little way into the skin, and they were not stimulated (moved or twisted) like true acupuncture needles would be.

There was moderate evidence that acupuncture was effective for short-term relief of pain. Relief of pain was directly linked with improved function, so it was inferred that acupuncture also improved function. There was conflicting evidence for pain relief over a longer (intermediate) amount of time.

When acupuncture was compared with other treatment (e.g., electrical stimulation, medication, massage), there was a wide range of results. Massage produced better short- and long-term results for improved function and pain relief. There was no difference between acupuncture and self-care. There was evidence that acupuncture combined with conventional therapy had the best results. But problems with study design and fewer than 40 patients in a group weakened the evidence. Specific comparisons between acupuncture and chiropractic care were not reported.

Opinions about the effectiveness of any treatment approach should be based on best practice and current evidence. As such, evidence-based medicine requires periodic review of published studies to see what’s new on various topics and treatment modalities.

In the area of acupuncture for low back pain, an updated systematic review is now available. Six new trials were included in this systematic review. These six were published in the last two years since the previous systematic review was performed.

There were many more studies done (1,606 with 40 of them random controlled trials), but they had to be high-quality to qualify as acceptable evidence. Only the six included were considered high enough quality to be selected.

There was moderate evidence that acupuncture was better than no treatment. At the same time, sham acupuncture worked just as well as true acupuncture. Sham acupuncture means the needles were not placed at true acupuncture points, they were only inserted a little way into the skin, and they were not stimulated (moved or twisted) like true acupuncture needles would be.

There was moderate evidence that acupuncture was effective for short-term relief of pain. Relief of pain was directly linked with improved function, so it was inferred that acupuncture also improved function. There was conflicting evidence for pain relief over a longer (intermediate) amount of time.

Even though there are still many questions to be answered, as a result of this updated systematic review, the European Guidelines for nonspecific back pain will now include acupuncture as an effective treatment for chronic low back pain. There is enough evidence that acupuncture is cost effective when compared with other treatments.

The Internet does offer a wide range of useful information. Even in the standard or usual care of low back pain, booklets or other reading materials are provided. These education materials are designed to help the patient understand back pain and its treatment.

Usual care for low back pain begins with education enouraging patients to keep moving. Rest is okay for a day or two but after that, patients are taught that motion is lotion. Sometimes patients are enrolled in an intensive course. The goal of this type of education is to help patients maintain active control of their own self-management program.

But sometimes self-management of problems like back pain isn’t effective. You may need an evaluation by a qualified health care professional such as an orthopedic surgeon or a physical therapist. They will help you determine the cause of the problem and offer a supervised rehab or retraining program.

If there’s no organic reason for your back pain such as infection, tumor, or fracture, it’s likely you have some type of mechanical low back pain. This means the source of the problem is within the joint and/or soft tissues of the spine. If that’s the case, you may need a specific type of exercise(s).

Studies show that fear-avoidance training helps patients move normally without fear of pain or reinjury. It is usually a behavioral approach designed to help the individual modify his or her activities, gradually moving toward full restoration of normal movement patterns. A physical therapist can evaluate you for fear-avoidance behavior and if needed, get you started on a fear-avoidance training program.

Get some outside help for your pain. Find out what’s causing it and seek professional help. A small investment now in terms of time and resources may save you lost work and wages in the long run.

Back school is a prevention and education program to help patients understand and care for their backs. Information about anatomy, posture, lifting, and exercise is presented over a period of weeks to months.

The goal is to raise patients’ awareness of their own bodies and increase their ability to function in everyday life. It’s usually presented to a group of people rather than on a one-on-one basis. Exercises are part of the program. Most back schools are taught by a physical therapist or other trained health care professional.

Back schools are still around, though they may not be called back school. The daily program or intense six-week program of the 1970s and 1980s has been replaced by a shorter course of instruction. Patients meet with a physical therapist for one to four sessions spread out over several weeks to a month. Some programs are extended up to eight weeks.

An example of this is the Back Care Boot Camp. The Back Care Boot Camp program is designed to be used with a physical therapist as a guide. The program consists of eight formal sessions of physical therapy and usually takes about four weeks to complete. The program is designed to educate the patient about the importance of spine health.

It also teaches ways to energize muscles again to protect the back and reduce the chances of having a future problem. Back Care Boot Camp gives immediate guidance to help head off potential long-term problems before they occur. You can find out more information about this program on this website www.backcarebootcamp.com.

People with lower back disc herniations, or bulging discs, sometimes have the option of having surgery or not to treat the problem. This isn’t an unusual situation and it’s good to hear that patients are being given this choice.

In your mother’s case, if her doctor truly feels that the decision is your mother’s, she needs to feel confident with her decision. Your mother should ask herself which she feels would work best for her. If she has high expectations for the nonsurgical treatments to work, studies have shown that the confidence usually translates into success and satisfaction with the decision. If your mother ends up feeling pressured into having surgery and she doesn’t have the confidence that it will work, she may end up unsatisfied.

Ultimately, the decision is up to her.

Over the years, there’s been a lot of debate about the source of pain felt in the sacroiliac joint (SIJ). Is it coming from the joint itself? From outside the joint? Or both? Studies show that it’s possible for soft tissue structures surrounding the joint to generate the same pain pattern as the joint itself.

One way to treat this is with physical therapy. The therapist works with patients to restore normal posture and biomechanics. This can help you regain normal movement patterns and stop the pain cycle. But in some cases, when the problem has been there for months (or longer), there are possible changes in how the pain is perpetuated (kept going).

Instead of being just a local problem of pinched soft tissues, misalignment of the bones, or an imbalance in the general body mechanics, the central nervous system has gotten in the act. Now there are central messages going from the spinal nerves up the spinal cord to the brain. This can set up a faulty, but permanent, neural pathway.

Using an anti-depressant as a neuromodulator helps reduce and possibly even eliminate the pain messages that don’t respond to any other outside treatment modalities. Usually, this type of approach is short-term (until the central nervous system is no longer part of the feedback loop).

When patients don’t want to use prescription drugs, there are other possible alternatives to change the way pain messages are processed and perceived. These are referred to as complementary and alternative medicine (CAM), energy medicine, or integrative medicine. There are many possible choices including reiki, acupuncture, naturopathy/homeopathy, BodyTalk, craniosacral therapy, and chiropractic or osteopathic care (to name a few).

You may find a center in your area that offers a variety of these energy medicines. It’s possible the pain center you went to has one or more alternative energy medicine practitioners on staff. Check with your doctor (or the pain clinic staff) first to find out what’s available. Explain your desire to explore other alternative treatment options. If nothing else works for you, you can always come back to the idea of trying an antidepressant for this purpose.

Back pain, especially in the lower back, can be very complicated. If the cause of the back pain is muscular or something that is very obvious, then doctors are usually able to identify it and offer the right treatments. However, not all causes are obvious and what may seem simple and clear, may not be in the long run.

When you see a doctor about back pain, you’re usually asked a lot of questions about your lifestyle so he or she can assess if the pain is being caused or made worse by some of your every day activities. X-rays and other diagnostic tests will show doctors if there is anything that can be actually seen, such as a fracture or a slipped disc. However, even despite the most thorough examination, it’s not always possible to tell what causes the pain and if the pain will be long lasting.

Work and work environments are often blamed for back pain. You read how-to articles on how to prevent back pain by either taking long breaks or changing your work environment. However, it’s not been found anywhere that it is mostly work that causes back pain so treating it as an “at-work” issue may not do you any good.

Many of the rules that may help reduce the risks of back pain are common sense rules, such as lifting with proper techniques (with your knees, not your back), but since you work in a sitting-down job, this may not even be your issue at work.

It’s been suggested by many people that by lowering your stress, changing your work environment to be more ergonomically correct, walking around regularly, and stretching, you will lower your risk of back pain. But those ideas aren’t backed up by research. You spend a significant amount of your day at home, not to mention commuting. Your bed, your home environment, your commute, may all be contributing to your back pain.