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Back pain FAQs

spine

What is it?

You'll know it if you've got it. It's a very common problem with a wide variety of possible causes.

What are the main symptoms?

Several symptoms, as listed below, are commonly associated with back pain. The diagram above shows the names of the different parts of the spine to which doctors or therapists might refer.

Pain that may be continuous or intermittent, and will probably be aggravated by movement. The pain may radiate upwards to the mid portion of the back, or downwards to the buttocks and thighs, and (rarely) around to the abdomen.
Muscle spasm, a severe type of muscle pain which causes the affected muscles to become knotty, tight and hard.
Sometimes a sharp, shooting pain may radiate from the back right down a leg to the ankle or into the foot. This is commonly known as sciatica. Sometimes the leg can feel tingly or heavy or there might be a burning sensation.
There may be numbness over a patch of skin and sometimes weakness of certain muscles so the sufferer cannot lift the big toe or foot (a foot drop). Sciatica and these symptoms suggest that a nerve is being irritated.
Rarely, there is numbness around the anus and incontinence of bladder, bowel or both. This is an emergency, requiring immediate medical attention.
Chronic (i.e. long-term) back pain can lead to depression, insomnia, loss of libido, hopelessness and sometimes suicide.

What's the risk?

A recent Government survey found that:

a staggering 40% of adults had suffered from back pain lasting more than one day in the previous twelve months
15% of back-pain sufferers said they were in pain throughout the year
nearly 40% of sufferers consulted a GP (now you know why GPs never have enough appointments!)
a third of back-pain sufferers said it had restricted their activity in the previous four weeks
5% of employed back-pain sufferers aged 16—64 had taken sick leave in the previous month because of pain

Another survey by the Arthritis and Rheumatism Research Council concluded that back pain accounts for 105 million lost working days every year.

What causes it?

There are so many different causes of low back pain that it would be impossible to list them all. Here are some of the more common ones:

trauma to the back, for instance by a blow or in a fall
prolapsed disc, where the tough coat of the cushion between two vertebrae tears, allowing the soft, inner part (the disc) to protrude and maybe irritate a passing nerve
tearing or strain of the ligaments supporting the spine
tearing or strain of the back muscles
poor posture
degenerative changes — so-called wear and tear in the spine
brittle bones which fracture easily — a condition known as osteoporosis And here are some not-so-common causes of back pain:
spondylolysis — a fracture in the arched part of a vertebra in the low back
spondylolisthesis — where one vertebra slips forward on another
scoliosis — curvature of the spine causing an unequal pull on the supporting muscles
facet joint problems — these are the small joints between vertebrae, which can get out of their normal alignment or can deteriorate with age
ankylosing spondylitis — an inflammatory arthritis of the spine of young men causing extreme stiffness and pain in the back
secondary tumours from say a primary lung cancer — these cause severe and continuous pain that gradually worsens and often causes insomnia (Other symptoms, such as weight loss and general malaise, are usually evident.)
referred pain — pain occurring as a result of a problem elsewhere but ultimately felt in the back (e.g. a urinary infection)

How can I prevent it?

Prevention is obviously better than cure! There are many day-to-day activities that can provoke back pain, and if you are aware of the correct ways to sit, stand, bend and lift this will help in prevention. Think about how you can modify the way in which you go about your daily life and work so that you don't put undue strain on your back.

When standing, try not to slouch. If you stand tall with your legs apart, and pull in your tummy, you will ensure that your lumbar spine curves inwards correctly. You may notice that people who have recurrent low back pain tend to have flat lumbar spines.
When sitting, get your buttocks against the back of the chair, ensuring you are as upright as possible. Put a cushion or soft support into the small of your back. If a chair is too low it will be a struggle to get out of, and back strain may ensue.
When bending down to pick something up, remember to squat with a straight back and bend your knees to lower yourself.
When lifting or carrying, where possible try to have the object (e.g. a heavy box) close to you and not at arms length where it can cause back strain. Use your legs to absorb some of the effort required to lift. If appropriate split the load so you are carrying two separate weights. This evens up the strain on the spine.
Keep your weight down. Excess weight puts a strain on the spine, which in turn makes low back pain more likely. If you are overweight it makes it more difficult to cope with low back pain and delays your recovery.
Gentle exercise, such as walking or swimming, increases the strength in the back muscles and improves mobility, which helps to reduce the likelihood of attacks of back pain. But it is vital not to overstretch in any direction as this may cause rather than prevent pain. If possible get advice from a qualified instructor to ensure you are doing an exercise correctly (e.g. the traditional sit-up with legs held down should be avoided).

Should I see a doctor?

Most attacks of low back pain are what doctors would term mechanical pain. This:

typically tends to affect people aged between 20 and 55
has a sudden onset, usually for a good reason
affects the back and maybe the thighs only, not the lower legs
is intermittent, and the pain is not severe at night

If your pain fits this description, and you are in good general health, you can start treatment yourself and only need to see your doctor if you are no better after two weeks.

If you have low back pain that is acute (i.e. it starts suddenly and is severe) combined with sciatica you should visit your GP sooner, as you may require:

confirmation of the diagnosis
strong painkillers
anti-inflammatory drugs
a sickness certificate
advice regarding other treatments
in exceptional cases you may be advised to see an orthopaedic surgeon or neurosurgeon if, for example, you have a foot drop or weakness affecting the big toe

Your back pain may rarely be an indicator of serious problems, in which case typically:

you may be aged under 20 or over 55
you may have a past history of cancer
the pain has come on slowly
several areas may be involved
the pain is severe at night and constant
you may have lost weight and have night sweats
you may be very stiff in the mornings, which takes some time to ease off

If your pain sounds like this see your doctor as soon as possible for further investigation.

Very rarely back pain can be felt in both lower legs, there may be numbness in the "saddle area", loss of bowel or bladder control, or weakness affecting both legs. This is an emergency and you must seek immediate medical attention.

So what will your doctor do? First, he or she will question you closely about your symptoms in an effort to categorise the pain. Then you will be examined, with particular attention paid to:

your posture
the range of movement of your back
whether you have full straight-leg raising (normally when lying down you should be able to lift each leg through 90 degrees without pain)
whether you have a patch of numbness or tingling
your reflexes
areas of tenderness in the back

Your doctor may ask for certain blood tests to be done and, depending on the circumstances, an X-ray may be indicated; for most patients, however, neither will be needed as they don't usually alter the way in which the problem is managed.

If your symptoms are persistent and severe, and back surgery is being contemplated, your GP will ask a specialist to see you. The specialist then may ask for:

a CT (computed tomography) scan
an MRI (magnetic resonance imaging) scan
a bone scan

What are the main treatments?

From the outset it is important to realise that there are many treatments advocated for back pain, and no one treatment will be effective for every patient. But it is worth mentioning that there is now definite evidence that a positive attitude to recovery is very important. For instance:

the so-called "AVOIDER" is frightened by pain, does not keep active, takes a lot of painkillers and is worried about the future — "Will I end up in a wheelchair?";
the "COPER" realises that the pain is only temporary and carries on with his/her normal life as far as possible;
AVOIDERS suffer more pain, take more sick leave and may become disabled;
COPERS suffer less, recover quicker and are less likely to be incapacitated long term. It is also known that people who are happier in their work are less likely to suffer from back pain.

It is important to remember that the vast majority of people with back pain do get better and that, even if it's very painful, back pain is very rarely caused by a serious problem and is highly unlikely to lead to a permanent disability.

Effective treatments for acute low back pain

Anti-inflammatory drugs

Otherwise known as NSAIDS (non-steroidal anti-inflammatory drugs), these drugs have been shown to help acute back pain. Examples include ibuprofen (which can be bought over the counter) and diclofenac (which is only available on prescription). Adverse side-effects can include indigestion, stomach ulcers and bleeding, particularly at prolonged, higher doses in older patients. Despite this, they are a first-line treatment.

Analgesics

Painkillers are also a first-choice treatment. Again, clinical trials have confirmed that they are effective, although the evidence is not quite as strong as for NSAIDS. Examples include paracetamol and co-proxamol. Adverse effects of strong analgesics can include drowsiness, dizziness and constipation.

Advice to remain active and patient education

It is now generally recognised that keeping active, and carrying on with life as normally as possible, speeds recovery from acute low back pain and reduces chronic disability. Bed rest should be limited to a couple of days at most.

Muscle relaxants

Research has found that this group of drugs (e.g. diazepam) can help in reducing pain but can cause drowsiness, dizziness and dependency if taken for prolonged periods. They may be useful particularly when there is a lot of muscle spasm.

Spinal manipulation

Osteopathy and chiropractic are the best known evidence-based techniques, although some physiotherapists also practice manipulative and mobilising techniques. These techniques improve function and provide pain relief. Side-effects are most unusual. They are probably best avoided where there is severe sciatic pain.

There is very limited or no evidence for the effectiveness of any of the following therapies for acute low back pain, but many patients swear by them:

physical treatments, such as ice, ultrasound, short-wave diathermy and massage
specific exercises
lumbar supports
acupuncture
epidural steroid injections when there is no sciatica
steroid injections into tender spots or facet joints
TENS (transcutaneous electrical nerve stimulation) machines
traction

Effective treatments for chronic back pain

Exercise

Clinical trials have shown that patients with persistent back pain have less pain and less time off work when they exercise. Walking and swimming are the least mechanically stressful forms of exercise.

Drugs

Analgesics and NSAIDS are effective, as in acute back pain. Bear in mind that the adverse effects of NSAIDS are more likely to occur if taken for prolonged periods.

Back exercises

Although these are not effective with acute back pain, the situation is different for chronic pain where back exercises improve pain and lessen sick leave.

Multidisciplinary treatment programmes and back schools

These have input from a physiotherapist and occupational therapist, and with multidisciplinary treatment programmes also from a psychologist. They have both been shown to have some benefit in improving pain and function. Information is given to sufferers about how the spine works and how to use the back wisely. Patients are advised how work can be made safer for the back. Since sufferers attend these courses together, they often get support and encouragement from each other.

Trigger point injections

Very often, in back pain, it is possible to identify small areas of the back that when pressed reproduce the back pain that the patient is complaining about. Combined injections of steroid and local anaesthetic can be effective in this situation when placed right into the tender spot (trigger point).

The following treatments have not been definitely shown to be effective, but this does not stop sufferers (who are often desperate for relief after years of pain) trying them:

muscle relaxants
epidural injections
lumbar supports
physical therapies, such as ice or heat massage
spinal manipulation by an osteopath or chiropractor
traction
TENS machine
acupuncture

There are also numerous other complementary therapies for back pain, including:

shiatsu (sometimes called acupressure)
aromatherapy
Alexander technique
Feldenkrais technique

Surgery

This is the last resort for the back-pain sufferer; it often leaves the back stiff and cannot be guaranteed to cure back pain. However, in selected cases removal of a damaged disc — a procedure known as a discectomy — can be very successful in relieving sciatica. Surgery can also be performed to stiffen a section of the spine, with the aim of preventing a spinal deformity increasing, or to relieve pressure on nerves from spinal stenosis where the spinal canal has become narrowed.

How can I help myself?

Get generally fitter as you will tolerate pain better.
Lose weight if necessary — if you are overweight it puts extra stress on the spine.
Think about how you move and lift before you act.
Make sure your bed and chair are supportive enough.
Avoid negative thinking, staying away from work, bed-rest, and pinning your hopes on a particular treatment.
Read the advice given in the "How can I prevent it?" section.

What's the outlook?

Acute low back pain is usually self-limiting: the vast majority (close to 90%) of people recover within six weeks. Approximately 2—7% of people develop chronic pain. The right treatment, as well as a positive attitude, can make a big difference.