Back pain is the most common musculoskeletal reason why patients see their doctors. It is a leading cause of disability around the world. Around 80-85% of adults get low back pain at some time and around 15-20% have a back pain episode in any one-year period. Back pain is most common in adults 30 - 55 years old, but can occur at any age. Younger or older people with back pain need careful attention, as the causes can be different at these ages.
In the UK over seven million people visit their GP each year with spinal pain. Over 3.4 million working days were lost in 2016 due to back pain. For this reason, back pain has often been described as the “scourge of modern society.”
Low Back Pain Causes
The cause of most people’s back pain is not known. Even where a diagnosis is given there is still significant doubt about the cause. Most cases are of the “non-specific” type. This means that there is no clearly identifiable reason for the condition.
- 1-2% have a serious underlying cause for their back pain and need medical review.
- Around 10-15% have a specific pathology such as spinal stenosis or a prolapsed disc.
- The remaining 85% are “non-specific”.
Major Types of Low Back Pain
Back pain and leg pain can present in a different ways and from many different causes. The main groups of diagnosis for back pain include:
- Mechanical low back pain
- Nerve root syndromes
- Pain syndromes
- Non-mechanical causes
Mechanical Low Back Pain
The cause of most back pain is unclear but changes in the intervertebral discs (IVDs) have often been blamed. The structure and makeup of the discs changes with time and these changes have been linked to pain. This is called disc degeneration or degenerative disc disease (DDD), although it is not a disease. But recent research has shown the link between disc degeneration and back pain is not strong.
Disc degeneration occurs in most people but is only painful (if indeed it is the cause) in a small minority.
Nerve Root Syndromes
A nerve root is the name given to the part of a nerve as it exits the spinal cord in preparation for running out into the body. The root has to pass through a narrow tunnel made up of the spinal bones above and below. Here it is most subject to compression or irritation.
Sciatica is the commonest nerve root problem, a severe pain surging down the leg and into the foot on one side. Low back pain is often present but not in all cases. Sciatica is caused by the herniation (bulging out) of a disc's central material through its outer casing onto a nearby nerve root. Patients can clearly tell where the pain is and it is often accompanied by changes in feeling (numbness, pins and needles) and reduced reflexes.
Other reasons for severe leg pain are spinal stenosis (more common over 60 years and can be in both legs), spinal changes in the discs and joints that limit the space for the nerve and Cauda Equina Syndrome (rare but important).
These conditions don't have obvious pathological changes to explain them but are common and disabling.
- Myofascial pain. Can be widespread with tenderness and pain over areas called trigger points. The muscles may be tight and have lost some of their movement. Treatment is to stretch the muscle groups and re-educate the way the patient uses their body. Evidence for this syndrome is not convincing although many people suffer from these symptoms.
- Fibromyalgia is a complex condition of widespread pain, tenderness, chronic fatigue, limited physical ability and stiffness.
Non-Mechanical Causes of Low Back Pain
Back pain that changes with the physical stresses on the back is called mechanical back pain. The causes of this are not well understood, but are presumed to involve the anatomy of the back. Other causes of back pain are termed non-mechanical.
Non-mechanical causes of back pain include fractures, infections, inflammation, arthritic diseases, osteoporosis and tumours. Non-mechanical back pain can be serious in cause and requires prompt medical investigation.
Risk Factors For Back Pain Include:
- Your age. You can have back pain at any stage of your life, but you are more likely to have it if you are in your 30s, 40s or 50s.
- Your body weight. Studies have identified a potential link between being overweight or obese and back pain.
- The kind of work you do. If your job involves repetitive tasks like typing, assembling or sewing, prolonged standing, sitting or bending.
- Repetitive heavy lifting, carrying, pushing or pulling and driving for long hours without taking breaks.
- Smoking. There is a general link here and also young male smokers may be more likely to suffer sciatica later in life.
- Accidents such as falls, or injuries.
- Pregnancy. Changes in weight, hormonal activity and posture may cause back pain, usually from the second trimester. This is common and not damaging.
Common Back Pain Symptoms
The symptoms of back pain vary from mild, localised muscle ache to severe shooting or stabbing pains down the leg and foot. There can also be limited ability to move the back or to stand up straight. The pain can be felt anywhere along the spine, from the neck to the pelvis. Most people have pain in the lower back, and describe it as muscle soreness, stiffness or tension.
In rare cases the following symptoms may develop:
- Loss of bladder or bowel control
- Numbness or alteration of feeling around the groin and genitals
- Pain in the abdomen (belly), or fever
- Unexplained weight loss
- Swelling or redness in the back
- Weakness, numbness or tingling in arms or legs (particularly if worsening)
You should see your GP at once if you notice any of these symptoms.
Why MRI Scans and X-rays May Harm Your Recovery
With more and more detailed MRI scanners we can see detailed images of what is going on in our lumbar spines. Strong efforts have been made to find the structures responsible for low back pain but have only been partly successful. This has led us to the mistaken idea that changes on a scan are responsible for the person’s pain symptoms.
MRI scans of people without back pain have shown interesting results:
- 91% have disc degeneration
- 56% show loss of disc height
- 64% have disc bulges
- 32% have disc protrusions (“slipped disc”)
- 38% have tears in the outer disc wall – annular tears
Changes in the lumbar discs increase with age but back pain does not, indicating the two are not closely linked. Having changes in your back does not predict that you are going to get back pain in the future. What is most closely linked to the likelihood of future back pain is depression.
Giving someone a diagnosis involving faulty anatomy of their back can increase their fear and disability. This can be directly caused by medical investigations and explanations. As MRI scans rarely lead to a change in treatment, they should be reserved for specific problems (e.g. severe sciatica) or potentially serious diagnoses.
Managing Back Pain
Back pain can develop suddenly after an event or over a long period of time perhaps due to repeated physical or mental stresses. It can be acute (short term) or chronic (long term). Acute back pain lasts from a few days to six to twelve weeks. Chronic back pain can last from three months to a lifetime.
The main type of treatment is known as “conservative treatment” which is really a secret code for “wait and see”. Conservative treatment does however seem to be the best way of managing most back pain and leg pain problems:
- Bed rest is not helpful for almost all back and leg pain conditions. Severe sciatica may benefit from two to three days of bed rest to reduce the irritability of the nerve. In all other pain problems, keeping going at a reduced level is much more important.
- Getting going with movement and strengthening exercises and an early return to work leads to better long-term results.
Treatment for Acute Back Pain
- Acute back pain is very seldom serious in nature and will resolve with time
- Maintain realistic thoughts such as “I'm having a severe episode but in a few days I'll be much better and able to get about”.
- Bed rest should be avoided unless pain is very severe
- Hot or cold packs may help some people
- Relaxation techniques may be useful, such as diaphragmatic breathing, listening to music or meditation
- Taking prescribed medication regularly, not just whenever the pain is bad
- Continue with your normal activities of daily living at a reduced level
- Taking time to achieve a comfortable sleeping position
Management of Chronic Back Pain
Chronic back pain can vary from episodes of back pain to low level backache most of the time to severe and disabling, continuous pain.
Treatment for chronic back pain is more complex than for acute pain and can involves different interventions. Chronic back pain is not just acute pain that lasts longer. It becomes something different as it develops and needs a different approach.
The management of chronic back pain involves exercise and physical fitness, pacing activity to avoid overdoing or avoiding, regular medications, psychological interventions and alterations to daily activities.
Referral to a pain management clinic may be necessary in cases of severe chronic back pain that has been unresponsive to normal treatments. Patients may attend a pain management programme to teach them the elements of self-management and how to get the best out of their lives under difficult circumstances.
This is known as treatment by a multidisciplinary team (MDT) as there are a number of different professionals involved – anaesthetists, nurses, physiotherapists, occupational therapists and clinical psychologists. MDT management has been shown to make modest but potentially important improvements in people with chronic back pain and psychological difficulties.
Recent research has indicated that Cognitive Functional Therapy (CFT) can have much better results than typical physiotherapy and MDT management. Many physiotherapists are turning to this method as it promised to change the pain problems of people who have been chronically disabled for many years. See this link for a patient’s view of the process http://www.mycuppajo.com/cognitive-functional-therapy/
Physiotherapy and Back Pain
Physiotherapists provide the majority of back pain care and treatment in the UK. A study published in The Lancet by researchers at Keele University (see reference 2) divided back pain sufferers into three groups by severity. Physiotherapists conducted the treatment of these groups and significant benefits were recorded in disability but also in quality of life, days off work, satisfaction with treatment and psychological functioning. Physiotherapists are healthcare professionals who can effectively identify, assess and address patients’ individual care needs.
Physiotherapy helps relieve pain through exercise, manual therapy and patient education. It can also help improve muscle flexibility and strength, balance, co-ordination and body posture, which in turn may reduce the likelihood of the pain recurring. Physical and social functioning can then improve and anxiety associated with the pain diminishes, which leads to better overall quality of life for patients.
How Can I Find A Qualified Physiotherapist Near Me?
Find a physiotherapist by entering a place or postcode in the Local Physio search box. All our practitioners on Local-Physio are qualified and registered with the Health and Care Professions Council (HCPC). Local Physio is extremely committed to treating patients who are experiencing pain and discomfort. From back pain to rehabilitation after an accident or injury, Local Physio will help you find the expert help you need.
- Ferguson F, Crawford A, Houston K, et al. Back in Control, Grünenthal
- Hill JC, Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet, Volume 378, Issue 9802, 29 October–4 November 2011, Pages 1560–1571
- Mayo Clinic, Back Pain, September 11, 2012
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, What is Back Pain? September 2009
- NHS Choices, Back Pain, March 11, 2013
- NHSinform Health Library, Causes of Back Pain, April 18, 2013
- Palmer KT, Walsh K, Bendall H, et al. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years. British Medical Journal, June 10, 2000; 320:1577
- The Backcare Charity, Causes of Back Pain
- University of Buffalo School of Medicine and Biomedical Sciences, What is Chronic Pain? Record #1 of 1ID: CD000963
- Kamper, Steven J et al, Multidisciplinary biopsychosocial rehabilitation for chronic low back pain, Cochrane Database of Systematic Reviews 2014
- Work-related Musculoskeletal Disorder (WRMSDs) Statistics, Great Britain 2016. http://www.hse.gov.uk/Statistics/causdis/musculoskeletal/msd.pdf