Most of us will suffer at least one episode of back pain at some point in our lives, and this will usually resolve spontaneously with some over-the-counter pain relief. When back pain is persistent, severe or starts to impact on living it becomes necessary to seek medical attention.
There are a number of causes of back pain, including disc disease and arthritis, however in the majority of people no specific cause is found. While this can be frustrating, it is also reassuring that a sinister disease is not apparent.
There are a number of treatments for back pain, including exercises, medications and back supports.The aims of treatment include:
- Managing pain
- Reducing time away from work
- Preventing the development of disability and dysfunction
- Minimising the psychological distress that frequently accompanies back pain
Very rarely, surgery can be used to treat back pain. However this will only be considered when:
- the cause of the back pain is known, for example, a slipped disc
- the potential benefits of surgery outweigh the risks
The non-surgical treatment options for back pain can generally produce a significant reduction in symptoms, allowing you to return to work and normal activities. However, it is important to keep in mind that the aim of treatment is always to reduce pain, as eliminating back pain altogether is notoriously difficult.
Symptoms
Back pain can be persistent or intermittent, worse with activity or rest, associated with specific movements or be completely inexplicable. The different patterns of pain reflect the different causes.
Additional symptoms that may accompany pain include:
- Shooting pain down the legs or into the buttocks
- Numbness and tingling around the groin, buttocks and down the legs
- Weakness in the legs
- Changes to bowel or bladder function. This can include difficulty urinating or using bowels or alternatively incontinence. Some men also develop erectile dysfunction with their back pain.
There are a number of other symptoms that may accompany back pain, but these are usually related to causes of pain outside the spine.
Causes
There are a number of causes of back pain but in the majority of sufferers no cause is found.
Possible causes of low back pain:
- Vertebral joints and discs
- Slipped disc
- Facet joint syndrome
- Spinal canal stenosis (see Lumbar Spinal Stenosis)
- Ligaments in and around the spine
- Arthritis –
- Osteoarthritis can occur in the spine
- Other forms of arthritis, like rheumatoid arthritis, can also affect the spine
- Ankylosing Spondylitis can cause low back pain but more commonly causes stiffness
- Spinal Instability (see Spondylolisthesis)
- Spinal deformity
- Scoliosis
- Kyphosis
- Fractures & Trauma
- Crush fractures
- Referred pain – organs in the pelvis and lower abdomen can sometimes cause a sensation of pain in the back.
Rarely, back pain can be caused by more dangerous conditions, like infection and cancer.
If your doctor has assessed you and cannot find a cause, try to feel reassured – no sinister cause has been identified. From this step on, you can begin working on controlling the pain.
Risk Factors
Back pain is common, so common that it is arguable that any animal moving on two legs rather than four is at ‘high risk’ for developing back pain. This means all humans are at risk, however factors that may increase risk include:
- Work that involves heavy manual labour. Performing activities that involve twisting or over-stretching the spine may also increase the risk of developing back pain.
- Obesity and smoking – these may or may not increase your risk of developing back pain.
- Previous injury or pain in the spine or other joints involved in walking, especially the hips and knees
Interestingly, the risk of developing chronic low back pain is more related to psychosocial factors than to the cause of the back pain. For example, someone who dislikes their work and is very concerned about their back is more likely to develop long-term pain than someone who is optimistic and can’t wait to return to work.
Investigations
Your doctor will need to thoroughly examine your back and legs before deciding if any tests are necessary. He or she may assess the movements and feeling of your spine and legs, your reflexes as well as trying to pinpoint the site of your pain.
Possible tests may include:
- X-Rays.
- Your doctor may ask for flexion-extension X-Rays in addition to the standard X-Rays. In these, you may need to bend forward or backward. These images can then be used to assess the stability and flexibility of your spine.
- Blood tests.
More sophisticated tests are ordered when your doctor is considering specific causes of pain.
- CT and MRI scan.
- Bone scan – this is a specialised test that identifies areas of bone that are undergoing lots of growth.
- Bone density scan. This scan is used to assess the weakness of your bones, and is often used to diagnose osteoporosis.
- Nerve conduction studies, EMG electromyography
Complications
Low back pain can make any movement at the spine painful, rendering normal activities like sitting or walking almost impossible.
If you have prolonged periods of rest associated with episodes of pain you can develop significant dysfunction in the musculoskeletal system in general. This can be a combination of:
- Deconditioning. Muscles that are not used regularly become weak and ‘lazy’. This softening of muscles leads of poorly balanced forces acting around the joints in the body.
- Joints that are not moved can become stiff and weak.
- Prolonged bed rest can lead to weakness in the bones. This usually only occurs after very long periods of reduced activity.
Treatment
Back pain can be incapacitating, and the urge to stop all activities and remain in bed can be very strong. While this is understandable, it is also very bad for your back and impairs your recovery.
There are four key points you should try to adhere to with back pain:
- Stay positive.
- If you are concerned by your pain or anything else, discuss things with your family, friends or doctor. It is normal to be distressed by pain, even when you’re doctor has reassured you that there is no identifiable cause. Rely on your loved ones to be empathetic.
- Pain is an emotional experience – nerves carrying the sensation of pain directly interact with the emotion system (the hippocampus and limbic system) in the brain. Addressing and relieving anxiety and distress is consequently a key component of treatment of chronic pain.
- Stay active.
- Bed rest for more than a few days after your initial injury is bad for your back and can lead to chronic weakness and dysfunction in your spine.
- Activities keep you feeling healthy and well, in addition to provoking healing and altering your perception of pain.
- Return to work as early as possible. Keeping your mind busy can prevent you from over-worrying and can provide support. It also prevents the growing difficulty of readjusting to work that occurs after long absences.
- Try simple things first.
- Exercise, limited rest and occasional use of over-the-counter pain medication effectively controls pain for most people.
- Try to use the lowest dose of medication possible to control your pain, rather than taking large doses.
- Prevent further injury.
- Take care of your back by adhering to your workplace’s safety regulations, by wearing lumbar support when appropriate and by avoiding activities that you know may provoke pain, like twisting, over-stretching or lifting heavy objects.
- Don’t take short cuts.
- Stay fit and maintain the strength in your abdominal muscles.
Activity, Exercise and Physical Therapy with Back Pain
Exercise of any kind may be uncomfortable initially, but will help to maintain the strength and function of your muscles. It is important to remember that your body is designed to move, not to lie still.
Exercises for low back pain may involve:
- Postural training.
- Abdominal muscle strengthening
- Reconditioning and increasing fitness with regular, low-stress aerobic exercise
Additional methods of controlling your pain include:
- Heat packs – applying warmth to your back can reduce pain
- Similarly, cold packs can be used
- Shoe inserts are sometimes recommended to assist with lower back pain
Things you should avoid:
- Prolonged bed rest
- Intense massage – while massage can be beneficial for lower back pain, intense massage performed by an untrained individual can be dangerous.
If your work requires physical activity, especially lifting, you should talk to your manager or OH&S advisor. In addition, you should be able to discuss correct ‘technique’ for lifting that uses your thighs and legs rather than your back.
Medications for Low Back Pain
It’s easy to forget sometimes that over-the-counter medications like panadol and ibuprofen are actually very effective in controlling pain.
- Ibuprofen – anti-inflammatory medications like nurofen are highly recommended for back pain. In most cases, your pain is a result of irritation and inflammation affecting the nerves. By reducing the inflammation and swelling, ibuprofen not only relieves your symptoms but helps speed recovery.
- Paracetamol – low doses of paracetamol can be taken over the day (always remain under the prescribed doses) to help reduce the background of pain. While paracetamol may not relieve the pain totally, it can help you get out of bed and get to work.
You can discuss these with your pharmacist and carefully read the label to make sure you are taking these drugs appropriately.
If these medications do not work, you should see your GP. Your doctor can refer you on to other healthcare professionals in your area as well as prescribe other pain medications. This may include:
- Opioids & other pain medications. A combination of paracetamol and an opioid, like codeine.
- Muscle relaxants.
- Anti-depressants. A particular class of anti-depressants, the tricyclics, are used to control pain because they affect the way nerves sense and carry pain.
- Spinal injections.
Surgery for Persistent Back Pain
Surgery for low back pain is only recommended in certain people. Options for surgery include:
- Spinal Fusion Surgery
- Disc surgery, including disc replacement or trimming of excess tissue
- Spinal decompression surgery
Seeking Advice
Your Family Doctor (GP)
Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and if necessary, refer you to Specialists (Consultants) for further treatment
When should I see my doctor?
If you have persistent progressive pain that is interfering with your daily activities and work, you can see your local doctor to discuss simple methods of controlling your pain.
If you’ve had back pain for many years and notice it suddenly changes, for example dull aches become sharp, or are accompanied by significant weight loss, you should see your doctor.
If you have the following symptoms, try to see your local doctor as soon as possible:
- Your bowel or bladder function has changed recently. In particular, if you seem to be losing control of your urine or your groin becomes numb see your doctor.
- You seem to be losing control of walking
- Your pain is present or worse at night time, and in particular if your pain is waking you.
- You wake up sweating profusely, have unexplained fevers of weight loss
- You have a past history of smoking or cancer
Prevention
General prevention:
- Maintain a healthy weight.
- Maintain the strength in your torso and legs, in particular your abdominal muscles.
- Stay active, even if you engage in low-stress activities like walking for 30 minutes a day, 3 times a week.
- Avoid footwear that alters your walking pattern, especially high-heeled shoes.
If you are at risk of developing weak bones or osteoporosis, you should see your GP. Risk factors include being female and post-menopausal.
You can prevent a single episode of back pain from becoming a recurrent problem by following the exercise program worked out with your physiotherapist or physical therapist.
Prevention in the workplace:
- Lifting & carrying objects
- You can protect your back by lifting heavy objects with your legs rather than your spine. To do this, stand with your feet shoulder-width apart, then keep your back straight as you bend your knees and hips to grasp the object. When you stand, your back should remain vertical while your legs, in particular your strong quadriceps in your thighs, push you upright.
- When carrying objects, try to hold your load as close to your chest as possible.
- Sitting down. When sitting for long periods at a desk or computer you can protect your back by:
- Maintaining a straight posture. Your lumbar spine is supported when you feel a slight inward curve along your lower back rather than the outward curve you get when you slouch. Some people can visualise this by thinking of a balloon on a string gently lifting their head up.
F.A.Q. | Frequently Asked Questions
References
Brotzman, S. B., ‘Chapter 9: Low Back Injuries’, in Clinical Orthopaedic Rehabilitation, 2nd Ed, by S. B. Brotzman & K. E. Wilk (Eds), Mosby Inc, 2003, Philadelphia, USA, pp 555-599.
Mercier, L. R., ‘Practical Orthopaedics’, 6th Ed, Mosby 2008, Philadelphia USA.