We get out of bed in the morning and our back hurts. At the end of the working day, the contractures take over our cervical or dorsal muscles. And it is that back pain is the most frequent chronic health problem in Spain, the first cause of requests for health care worldwide and the main cause of disability and loss of work for health reasons. 80% of the population suffers from back pain at some point in their lives.

Dr. Francisco Kovacs, director of the Back Unit of the HLA-Moncloa University Hospital, in Madrid, and of the National Network of Back Ailments Researchers, explains it to us. Graduated in Medicine and Surgery from the University of Barcelona in 1983, he is one of the leading specialists on the subject in our country. In a conversation with La Vanguardia from the other side of the Atlantic, he gives us a fast-paced master class on the types of pain, treatments and lifestyle habits that influence it.

80% of people suffer from back pain at some point. It’s a barbarity. How is it explained? Does it have to do with the current lifestyle?

Back pain has been common throughout history, but studies have shown that some factors of modern life can increase its frequency. The most important is a sedentary lifestyle, a life with little physical activity; that is, within the modifiable factors, the lack of physical exercise is the one that influences the most. It has been shown that back pain is reversible, physical activity has a preventive effect and also shortens the episode of pain.

If our back hurts, should we continue exercising to heal?

Bed rest is inherently harmful, and especially if it lasts for more than 48 hours. Muscle tone worsens, as does the coordination of the different muscle groups that support the back. That makes it easier for an episode to occur or repeat itself later. Maintaining as much activity as the pain allows shortens the episode and reduces the risk of recurrence. The advice is to move as much as you can, even during the painful episode.

What sport or exercise is best to prevent back pain? There is always talk of yoga or pilates, as well as swimming…

Any physical activity is better than none, as long as common sense is maintained to avoid anything that increases the intensity of pain. From a preventive point of view, this maxim applies completely: do the exercise you want, but do something. The important thing is to maintain a physical exercise over time and for that, the more the person likes it, the better. The type of exercise must be prescribed for each patient according to her tastes and according to the probability that she will do it continuously and systematically.

And in the case of treatment, when there is already pain?

In the midst of an acute episode of pain, it is advisable not to make great efforts, but to maintain as much physical activity as possible. We must avoid the loss of muscle tone and coordination that would entail the fact of doing nothing. For chronic patients, where muscle imbalances between different groups that contribute to keeping the back straight are more likely to have developed, specific exercises may be appropriate.

Does the exercise strengthen the back muscles and thus prevent pain?

It is so, but when we say strengthen we also refer to the coordination of the muscles. When I was studying, it was considered that the spine was kept straight by the position of the vertebrae. The back is actually kept straight, just like the mast of a ship, not because of the structure, but because of the dynamic tension of the strings that are inserted into the mast, they have a tension. In the case of the spine, the principle is the same, but it is also constantly moving when we walk or when we change posture. The tension of the different muscle groups is constantly adjusting to help maintain the center of gravity.

What are the warning signs, if there is back pain? When do we have to go to the doctor?

First, if there are neurological symptoms, if the pain radiates to the arms, legs or viscera. Also if the pain is tremendously intense, even taking drugs. Third, if the pain persists for more than 14 days, even if it is not very intense. It is also necessary to consult if there is a fever, weight loss, tiredness, etc. All this, except in children, since under eight to ten years of age, back pain is much less frequent and the percentage of cases in which it is due to a disease is higher. If a child has back pain, you should always go to a consultation.

What are the most common causes of back pain?

Only in 1% of cases the pain is due to a disease that manifests itself in the back, but which is not itself of it: cancer, infections, irradiated visceral diseases, metabolic diseases… In 4% of cases it is due to a structural alteration of the spine that is irritating or compressing a nerve, as happens in cases of herniated discs or spinal stenosis. In the remaining 95% of cases the cause is a malfunction of the muscles, contracture and inflammation are self-perpetuating.

So, in most cases is back pain reversible?

Nowadays it is exceptional that it does not have treatment. The most complicated case today is the syndrome of surgical failure, the patient who has undergone surgery, the indication has not been successful or the scar itself in the operation compresses a nerve and produces intense pain. This has a solution, but it is one of the most difficult cases.

According to you, the diagnosis should be made by questioning the patient and physically examining him first…

Complementary tests, MRIs, X-rays, etc., as the name suggests, are complementary. The result of the imaging tests without the previous information from the examination and the interrogation is useless or counterproductive.

What problems do unnecessary medical tests generate?

On the one hand, they have secondary defects. A CT generates an irradiation dose that is equivalent to up to 400 lung X-rays and it is estimated that between two and 3% of the tumors that will appear in the future are due to excessive irradiation caused by unnecessary tests. Other imaging tests such as MRI do not have side effects in themselves, but they do have imperceptible harmful consequences. In an MRI, such subtle things are seen that in many healthy patients without any pain, findings are detected that can be interpreted as unhealthy. 70% of healthy people who walk down the street without pain show protrusions or herniated discs on their magnetic resonances that are of no importance.

There can begin an ordeal of doctors and erroneous operations… Is that so?

Doing an MRI when it is not indicated increases by 800% the probability that the patient will be operated on unnecessarily, so it is recommended not to do routine imaging tests. It is only advisable to do them when the information gathered by the questioning and examination reflect that the test can be used to confirm the diagnosis or to clarify the treatment. If someone invites you to have an MRI, do it only to rule out that there may be a systemic disease that causes pain or in cases where there may be a surgical indication.

The time to get out of bed is the great moment of back pain. What should the mattress we sleep on be like?

A few years ago the prescription was that the bed should be the harder the better. We did a study in Spain that was the first clinical trial to evaluate how the mattress should be in a patient with back pain, comparing a very firm mattress with another of intermediate firmness. A medium-firm mattress is better than a very hard one, it needs to be firm enough to keep you flat and not sag like a hammock, but soft enough to accommodate the normal curves of your spine, such as the lumbar curve.

With the ideal sleeping posture there is some confusion. Sideways or face up?

Most patients are better off on their side in the fetal position, but the clinical trial showed that the type of mattress carried much more weight than the position. The tension of the muscle groups automatically changes posture during sleep. Trying to control posture is complicated and unnecessary. In the midst of a pain crisis, most patients tend to be more relieved if they sleep in the fetal position with a pillow or something between their legs, to align the leg with the hip.

Does postural hygiene influence back pain?

If you work eight hours a day on your computer and have a crooked screen that forces you to be crooked, this can have an effect. But beyond exaggerated cases like this, in general, all the therapeutic or preventive efforts invested in postural hygiene have no effect. However, look at how professional dancers walk, how they float; It is not because they are thinking about how they have to walk, but because of the exercise they have done, they have muscle tone that makes them adopt a very good posture without thinking about it.

How important is footwear in back pain?

There are no clinical trials to confirm the influence of the shoe on back pain. Now, the knowledge we have says that the width of the heel, the height and the type of surface influence. Anyone who has to be on their feet for many hours should wear shoes whose surface has a certain cushioning capacity. Ideally, the foot should not be compressed, but tight, so that the back and leg muscles are not floating on an unstable surface that you have to constantly correct. A particularly high and thin heel forces the lower back muscles to work.

What non-prescription medication is most effective in relieving regular back pain?

In an acute episode, nonsteroidal anti-inflammatory drugs have been shown to have an effect, whereas muscle relaxants have little or no effect. Pain relievers are not meant to cure the cause of the pain, just to make it hurt less. For years doctors prescribed paracetamol thinking that it has fewer side effects, but a tremendously rigorous clinical trial showed that this is a mistake in the specific case of back pain. Paracetamol has no more effect than placebo, it makes no sense to take it for this discomfort.

And is it better to apply heat or cold?

The heat relaxes the muscles and improves blood flow and the most effective is to apply it for 25 or 30 minutes and repeat it when necessary (do not leave it longer in a row). For its part, cold reduces inflammation. In general, heat is recommended in chronic patients or in pain that is due to muscle contracture. However, in the acute phases of a recent injury, cold works best. You can try hot or cold and see how they work, neither heat nor cold is going to trigger any lingering side effects.

More than two hundred treatments are applied in the world of the back. Is there a lot of marketing and new products, due to the fact that it is a very frequent pain?

There are many treatments, but very few that have been tested rigorously enough to know if they work. Of those that have been tested, some have been shown to be effective in some specific cases and many have been shown not to be. Unfortunately, proven effective treatments are not always applied. In clinical practice, what determines whether something is used or not used does not always have to do with science.

Some examples?

One technology that has been shown to be effective but is abused is surgery. There are techniques that have been shown to contribute nothing and are still being done because there are economic interests. In the United States there are cases of bribery of companies that manufacture surgical material and bribe doctors to apply it, although it is not indicated. In the case of effective treatments that are not applied systematically, the most bleeding case is neuroreflexotherapy, which has proven to be effective in specific cases of pain that has lasted many days and is not due to spinal stenosis.