Understanding Back pain
Your guide to understanding the basics on backpain, please remember this is a guide and doesn’t substitute seeing your doctor or healthcare practitioner such as your osteopath, however, the more you know and understand the more you can manage your backpain.
Here we are going to look at;
Symptoms of backpain
Types of backpain; Specific and non specific causes
How is non-specific back pain diagnosed?
Do you need any tests for your back pain?
Exercise for back pain
NICE – a national guide line
Can back pain be prevented?
Symptoms of back pain
With back pain there are many symptoms which can be experienced such as tension, soreness or stiffness in your lower back area. This pain is often referred to as ‘non-specific’ back pain and can improve on its own within a few days.
Back pain can be called ‘acute’ or ‘chronic’ depending on how long your symptoms last. You may have:
acute back pain – lasts less than six weeks
sub-acute back back pain – lasting six weeks to three months
chronic back pain – lasting longer than three months
Red flags – If you are experiencing backpain you should contact your GP as soon as possible if you have:
Inflammation or swelling on the back,
Constant pain, particularly at night
Constant back pain that doesn’t ease after lying down or resting,
Pain that travels to the chest or pain high up in your back,
Pain down the legs and below the knees,
A recent trauma or injury to your back,
Loss of bladder control,
Inability to pass urine,
Loss of bowel control,
Numbness around the genitals, buttocks or anus.
These signs are referred to as red flags and it’s important to seek medical help, with the main reason to rule out any serious underlying cause for you back pain.
You should also seek medical advice if you’re experiencing back pain and:
You’re under 20 years old or over 55 years,
You have taken steroids for a few months,
You are a regular drug user,
You have or have had cancer, or
You have a low immune system due to chemotherapy or another medical condition (for example, HIV/AIDS).
Types of back pain?
Back pain can be specific or non specific, specific back pain could be nerve pain, cauda equina, accident or disc prolapsed (often referred to as slipped disc though discs don’t actually slip). Back pain with no obvious action, trauma or disease is called non specific
Nerve root pain – sciatica is one of the nerves regularly irritated 9often referred to as trapped)
Back pain from nerve root pain means that a nerve coming out from the spinal cord (the ‘root’ of the nerve) is irritated or pressed on. You may have back pain which is accompanied with pain along the course of the nerve, the sciatic nerve can be felt like a straight line of pain along the back of the leg and sometimes as far as to the calf or foot. The pain in the leg or foot is often worse than the pain in the back. With nerve irritation other sensations may also be felt such as pins and needles, numbness or weakness in part of a buttock, leg or foot.
Back pain which originate from a nerve root irritation which is compressed due to a prolapsed disc – often called a ‘slipped disc’. (There is not an actual ‘slip’ but occurs when part of the inner softer part of the disc bulges out (prolapses) through a weakness in the outer harder part of the disc. The prolapsed part of the disc can press on a nerve nearby).
Cauda equina syndrome – rare, but an emergency
Cauda equina syndrome is a particularly serious type of nerve root problem. This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus: problems with bowel and bladder function (usually unable to pass urine), numbness in the ‘saddle’ area (around the anus), and weakness in one or both legs.
Due to the bladder and bowel involvement and to prevent permanent damage urgent treatment is needed, so if you suspect cauda-equina see you doctor immediately.
Less common causes of low back pain
Arthritis (inflammation of the joints) of the spine sometimes causes back pain. Osteoarthritis is the common form or arthritis and usually occurs in older people.
Ankylosing spondylitis is a chronic, inflammatory arthritis and autoimmune disease. It mainly affects joints in the spine and the sacroilium in the pelvis, and can cause eventual fusion of the spine.
Various uncommon bone disorders, tumours, infections, and pressure from structures near to the spine occasionally cause low back pain.
Non-specific lower back pain?
Non-specific low back pain means that the pain is not due to any specific or underlying disease that can be found. It is thought that in some cases the cause may be a sprain (an over-stretch) of a ligament or muscle. In other cases the cause may be a minor problem with a disc between two vertebrae, or a minor problem with a small ‘facet’ joint between two vertebrae. There may be many influencing factors involved in your back pain such as you posture, any repetitive action at work, no exercise, excessive exercise or poor exercise methods, all these can give major and minor problems in the structures and tissues of the lower back that result in pain.
What are the symptoms of non-specific low back pain?
Sometimes a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. Sometimes it can develop for no obvious reason. Some people just wake up one day with back pain.
Although non-specific back pain is sometimes called ‘simple’ back pain, simple does not mean that the pain is mild. Lower back pain can be anything from mild to severe. Typically, the pain is in one area of the lower back, but sometimes it spreads to one or both buttocks or thighs. The pain is usually eased by taking pressure of the underlying structures, so non-specific lower back pain is ‘mechanical’ in the sense that it varies with posture and activity.
Most people with a bout of non-specific low back pain improve quickly, usually within a week or so, sometimes a bit longer. However, once the pain has eased or gone it is common to have further bouts of pain (recurrences) from time to time in the future. Also, it is common to have minor pains ‘on and off’ for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer. This is called chronic back pain (discussed in more detail later).
How is non-specific back pain diagnosed?
Firstly professional help is advised as you need to understand the mechanics of your back pain then, you need to understand the tissues and structures involved, i.e. ligaments, tendons, discs, muscles and joints etc.
Most people who develop low back pain that comes on suddenly (acutely) have non-specific lower back pain. If there are no other associated symptoms and the pain is not too bad, many people are confident to just ‘get on with it’ and treat it themselves – and often get better quickly.
When your back pain is not resolving then consider visiting an osteopath, chiropractor or physiotherapist, these professionals deal with muscular skeletal disorders and where necessary refer for further investigation.
If you have any red flags then see a professional or GP, but note: the vast majority of people with lower back pain do not have any serious signs or symptoms.
Do you need any tests for your back pain?
Usually not. Your professional or doctor will usually be able to diagnose non-specific low back pain from the description of the pain, and by examining you. There are many tests that can help you understands the mechanics involved in non-specific low back pain. In a diagnosis of non-specific low back pain technical jargon can be used to report on some scans can sometimes sound alarming, when in fact the scan is just showing what would be normal for a given age and not a cause for pain. However it should also be noted that if someone is assessing your back they should be able to distinguish which structures are involved so you can take the appropriate action, i.e. if you have a nerve irritation then which one? how can you confirm this? Femoral nerve root irritation involves different structures to sciatic irritation, an irritation to the facet in the lumbar spine behaves differently to a sacroiliac joint dysfunction and what will ease one structure can give pain in another. If you are told it’s a muscle sprain which one, what does it do? What aggravates it? What relives the tension? These are questions a professional should answer.
Current UK guidelines are clear that routine tests such as X-rays and scans should not be done if the diagnosis is made of non-specific low back pain.
Tests such as X-rays or scans may be advised in certain situations. This is mainly if there are symptoms, red flags or signs during an examination to suggest that there may be a serious underlying cause for the back pain.
What are the treatments for non-specific low back pain?
The following advice and treatment is commonly given for a sudden ‘acute’ bout of non-specific low back pain.
Exercise – keep going
Continue with normal activities as much as possible. This may not be possible at first if the pain is very bad. However, move around as soon as you are able, and get back into normal activities as soon as you can. As a rule avoid anything that causes a lot of pain. However, you will have to accept some discomfort when you are trying to keep active. Setting a new goal each day may be a good idea to help a progressive return to movement, for example, walking around the house on one day, a walk to the shops the next, etc.
To help rehabilitate your back pain exercise and activities are going to be a major influence, a very important factor with exercise is that it needs to be fit for purpose, i.e. if you work at a desk all day then core stability and posture are needed such as Pilates, weight training (to a programme) and core stability exercise, If you are a electrician you need core stability exercise, posture awareness and the ability to stretch as your work is generally in awkward positions with a strain on your back and joints so swimming backstroke, crawl would be good or even yoga, some activities such as running in certain conditions just wouldn’t give you the necessary movements to assists in the rehabilitation of back pain.
The better your body’s physical condition the more able you are placed to rehabilitate you Back pain and response to treatment.
Back pain recovery can also be influenced by your sleep; therefore you need to sleep in the most naturally comfortable position on whatever is the most comfortable surface. Advice given in the past used to be to sleep on a firm mattress. However, there is no evidence to say that a firm mattress is better than any other type of mattress for people with low back pain. Some people find that a small firm pillow between the knees when sleeping on the side helps to ease symptoms at night. Sleep and mattresses can be influence by your spinal shape; a deep lumbar curve will have different requirements to someone with a very flat spine.
If you have a job, aim to get back to work as soon as possible. There is no need to wait for complete freedom from pain before returning to work. Returning to work often helps to relieve pain by getting back to a normal pattern of activity and providing a distraction from the pain.
In the past, advice had been to rest and lie flat until the pain eases. It is now known that this was wrong. The evidence from research trials is that you are likely to recover more quickly by getting moving again, and getting back to work as soon as possible. Also, you are less likely to develop chronic (persistent) back pain if you keep active when you have back pain rather than rest a lot.
Medication (always take advise from your GP or Pharmacist)
If you need painkillers, it is best to take them regularly. This is better than taking them ‘now and again’ just when the pain is very bad. If you take them regularly the pain is more likely to be eased for much of the time and enable you to work on your mobility and keep active.
Paracetamol is often sufficient if you take it regularly at full strength
Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac or naproxen need a prescription. Some people may not be able to take anti-inflammatories. For example, some people with asthma, high blood pressure, kidney failure, or heart failure.
A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. This may make lower back pain worse if you need to strain to go to the toilet. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
A muscle relaxant such as diazepam is occasionally prescribed for a few days if the back muscles become very tense and make the pain worse.
Remember always to take advise from your GP or pharmacist with medication.
Heat such as a hot bath may help to ease pain; heat can help relax muscles which can reduce tension from the area involved.
Treatment may vary, and the situation should be reviewed by a doctor if the pain becomes worse, or if the pain persists beyond 4-6 weeks, or if symptoms change. Other pain relieving techniques may be tried if the pain becomes chronic (persistent).
back pain – what the future holds
As back pain is so common, most of us (about 8 in 10 people) will have a bout of non-specific low back pain at some point in our life. Figures are difficult to give because as so often there is a lot of people who don’t get treatment and simply get on with it, as a guide it is thought:
Most non-specific back pains ease and go quickly, usually within a week or so.
In about 7 in 10 cases, the pain has either gone or has greatly eased within four weeks.
In about 9 in 10 cases the pain has gone or has greatly eased within six weeks.
However, once the pain has eased or gone it is common to have further bouts of pain (recurrences) from time to time in the future. Also, it is common to have minor pains ‘on and off’ for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer. This is called chronic back pain.
Chronic (persistent) non-specific low back pain
Non-specific low back pain is classed as chronic (persistent) if it lasts longer than six weeks. In some people it lasts for months, or even years. Symptoms may be constant. However, the more usual pattern is where symptoms follow an irregular course. That is, reasonably long periods of mild or moderate pain may be interrupted by bouts of more severe pain.
What is the treatment for chronic non-specific low back pain
Initial treatment is similar to ‘acute’ attacks. That is, aim to keep as active as possible. Also, painkillers can help. In addition to the painkillers listed above, your doctor may advise a course of an antidepressant medicine in the ‘tricyclic’ group, for example, amitriptyline. Tricyclic antidepressants have other actions separate to their action on depression. They are used in a variety of painful conditions, including back pain.
NICE – a national guide line
Nice recommends one or more of the following treatments should be considered. Each of these treatments has some evidence from research trials to suggest that they will help to ease symptoms in some people (but not all):
Structured exercise programme. This means a programme of exercise supervised by a professional such as a physiotherapist. This is likely to be in a group setting. Exercises may include aerobic activity, movement instruction, muscle strengthening, posture control and stretching. It typically consists of up to eight supervised sessions over 8-12 weeks with encouragement to keep on doing the exercises at home between sessions.
Manual therapy. Typically this includes several sessions of massage, spinal mobilisation and/or spinal manipulation. With spinal mobilisation the therapist moves the joints of the spine around in their normal movement range. In spinal manipulation, the therapist moves joints beyond the usual range of movement.
A course of acupuncture treatment.
Cognitive behaviour therapy (CBT) may also be recommended as a treatment option. There is good evidence from research trials that it can help. CBT aims to help you to change the way that you think, feel and behave. It is used as a treatment for various health problems including various types of chronic pain.
If the above treatments have not helped much then you may be referred to a specialist pain clinic. Rarely, a surgical operation called spinal fusion is considered when all other treatment options have not helped and pain remains constant and severe.
Can back pain be prevented?
Evidence suggests that the best way to prevent bouts of back pain is simply to keep active, and to exercise regularly. This means general fitness exercise such as walking, running, swimming, etc. There is no firm evidence to say that any particular ‘back strengthening’ exercises are more useful to prevent back pain than simply keeping fit and active, however its common sense to know that some exercise is better than others, If your GP or professional recommends certain exercise then you need to know why, what structures are involved and how they be affected. It is also sensible to be ‘back aware’. For example, do not lift objects when you are in an awkward twisting posture.