Back Pain

What Causes Back Pain?

The back is a complex structure made up of:

  • Bones of the vertebrae
  • Muscles
  • Nerves
  • Joints

Because of this complex structure it is difficult to pinpoint the exact cause of the pain. In most cases the pain is not caused by serious damage or disease but by sprains, minor strains, minor injuries or an irritated nerve ending. These may be triggered by an awkward position, everyday activities at home and at work, lifting or standing awkwardly or as a result of longstanding bad posture.

Common causes of back pain

Common causes include:

  • Lifting, carrying, pushing or pulling incorrectly
  • Twisting the back
  • Sprains and injuries
  • Bending awkwardly
  • Sleeping or getting up from the bed awkwardly
  • Overreaching or stretching
  • Slouching while sitting
  • Driving in a hunched position
  • Bending or standing for long periods of time
  • Driving for long hours without breaks
  • Sitting at the desk for long hours without change in posture
  • Repetitive strain injury
  • Unaccustomed exercise
  • Bad or uneven heeled shoes
  • Ankylosing spondylosis
  • Whiplash injury
  • Frozen shoulder
  • Slipped or bulging disc (this disc lies like a cushion between two vertebrae)
  • Sciatica
  • Arthritis
  • Osteoporosis and vertebral fractures
  • Skeletal irregularities (e.g., scoliosis, kyphosis, lordosis, back extension, back flexion) and conditions such as fibromyalgia, kidney stones or infections, endometriosis etc. More serious causes include cauda equine syndrome, bone cancers, spine infections

Risk factors for back pain

Some persons are typically more prone to getting back pain. Most persons however get back pain at some point in their lifetime. The following are risk factors for back pain:

  • Age – Back pain typically occurs between the ages of 30 and 40. It becomes more common with age
  • Level of fitness - Back pain is more common among people who are not physically fit. these individuals have weak back muscles.
  • Pregnancy – Pregnancy may put a great strain on the back especially at later stages and there may be a dull back pain.
  • Occupation – Persons who need to lift, push or pull and twist their backs at work, they may be at risk of back pain. Those working for long hours at their desks are also at risk of back pain.
  • Stress – this leads to strain of the back muscles and stiffness that may give rise to back pain.
  • Being overweight or obese – These individuals have too much stress on their spine that may lead to pain.
  • Inherited - Some causes of back pain, such as disc disease may be inherited.
  • Ethnicity and race - African American women are found to be two to three times more likely than white women to develop spondylolisthesis. Caucasian women of northern European heritage, on the other hand, are at the highest risk of developing osteoporosis.
  • Smoking - Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.
  • Long term use of medications like corticosteroids. These weaken the bones and make them prone to fractures and injury.
  • Depressive illness – those with depression are also prone to getting back pain.
  • Other diseases – Those with arthritis and cancers with spread to bones may also experience back pain.
The muscles in your shoulder are connected to your arm by tendons. Between the tendons and bones are small sacs of fluid called bursa. They lubricate the shoulder so it moves easily. Continual stress on your shoulder can cause the bursa to get squeezed, swollen, stiff, and inflamed (bursitis). Bursitis can make it painful, or even impossible, to raise your arm. Image Credit: CDC

 

If you bend forward over and over for months or years, the discs are weakened, which may lead to disc rupture (or "herniation"). Image Credit: CDC

What is Back Pain?

Back pain is a common symptom and affects most people at some point in their life. An estimated 75 to 85 percent of all Americans will experience some form of back pain during their lifetime. Most countries take a major blow to their productivity due to back pain through loss of workers on sick leave.

Some national governments, notably Australia and the United Kingdom, have launched campaigns of public health awareness to help combat the problem. One of these is the Health and Safety Executive's Better Backs campaign.

What does back pain feel like?

In most cases rather than an acute stabbing pain, it is a dull stiffness or tension in the back. The pain can be triggered by an awkward posture, bending or sitting awkwardly, or lifting incorrectly. 

Usually back pain is not a serious disease and usually gets better by 12 weeks. Exercises and pain relievers and advice of good posture maintenance is the treatment of choice.

Types of back pain

Back pain may occur at any part of the back but commonly affects the lower back. The pain may also be felt along the spine, neck or hips. Common types of back pain include:

  • Neck pain
  • Ankylosing spondylosis
  • Whiplash injury
  • Sprains and injuries
  • Frozen shoulder
  • Slipped or bulging disc (this lies like a cushion between two vertebrae)
  • Sciatica
  • Arthritis
  • Osteoporosis and vertebral fractures
  • Skeletal irregularities (e.g., scoliosis, kyphosis, lordosis, back extension, back flexion)
  • Other conditions include fibromyalgia, stress, pregnancy, kidney stones or infections, endometriosis etc.
  • More serious causes include cauda equine syndrome, bone cancers, spine infections

Causes of back pain

Risk factors for back pain:

  • Age – Back pain typically occurs between the ages of 30 and 40. It becomes more common with age.
  • Being overweight or obese – These individuals have too much stress on their spine that may lead to pain.
  • Level of fitness - Back pain is more common among people who are not physically fit, these individuals have weak back muscles.
  • Occupation – Persons who need to lift, push or pull and twist their backs at work, they may be at risk of back pain. Those working for long hours at their desks are also at risk of back pain.
  • Inherited - Some causes of back pain, such as disc disease may be inherited.
  • Ethnicity - African American women are found to be two to three times more likely than white women to develop spondylolisthesis. Caucasian women of northern European heritage, on the other hand, are at the highest risk of developing osteoporosis.
  • Smoking - Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.
  • Other diseases – Those with arthritis and cancers with spread to bones may also experience back pain.

Warning signs of back pain

In most cases a few days of rest and adequate mobility may help in recovery from back pain. However, some symptoms may indicate a deeper problem and mandates a visit to the doctor. These symptoms include:

  • Weight loss that is unexplained
  • Swelling and immobility of the back
  • Fever
  • Pain in the limbs
  • Numbness of the lower limbs or other parts of the body including genitals
  • Loss of bladder or bowel control
  • Worsening pain at night

Treatment of back pain

The primary modality of treatment is by remaining mobile and active. Earlier bed rest was advised for back pain. These days it is known that being inactive for long periods is actually bad for the back. Patient is advised moderate activities such as walking and doing their own daily tasks.

Pain relievers like Acetaminophen (Paracetamol) is commonly advised. Hot or cold compression packs may also help reduce the pain. There are other manual therapies including physiotherapy and osteopathy. These may also help relieve pain.

For back pain lasting for more than six weeks exercise classes or manual therapy along with pain relievers are advised. Acupuncture may provide relief in some individuals. Spinal surgery is usually only considered when all else has failed.

Prevention of back pain

  • Maintenance of good posture while sitting, standing, lifting, lying down.
  • Getting up from sitting or lying position is another important factor that needs to be improved to prevent strain to the back.
  • Individuals are advised not to place too much pressure on the back and ensure their back is strong and supple.
  • Regular exercise, such as walking and swimming, is an excellent way of preventing back pain. Yoga and pilates also improve the flexibility and strength of the back muscles.

Back Pain in Pregnancy

Back pain may affect pregnant women especially during later stages of their pregnancy. The prevalence of back pain during pregnancy is 48 - 56%. In fact it is so common that in most cases this symptom is looked upon as a normal part of pregnancy.

Around a third of all pregnant women may get severe back pain that compromises their ability to work in gainful employment during pregnancy and also interferes with their activities of daily living. Furthermore, back pain occurs at night in over one-third of pregnant women, contributing significantly to insomnia.

Pregnancy related back pain and risk factors

  • Pregnancy-related back pain is commonly seen in women who have a history of previous episodes of back pain.
  • The pain is usually most intense from the 12th week of pregnancy till 28th week and usually declines in intensity after that.
  • Women with twin pregnancies or in later pregnancies (after the first pregnancy) may be more at risk of back pain. 
  • Pregnancy related back pain may also be related to long hours of work and bad posture. Even bad shoes and heels and long hours of standing can contribute to back pain in a pregnant women.
  • Furthermore Hispanic women have a proportionally lower instance of back pain in pregnancy than Caucasian women. 
  • Younger age is also a risk factor, possibly due to higher sensitivity to hormonal   changes  induced by relaxin  and estrogens,  or  to more  pronounced collagen laxity
  • Higher weight (obesity and overweight mothers) and those with a short stature are at higher risk of back pain
  • Women who have had pain during pregnancy are also more likely to suffer from back pain after childbirth.

Mechanism of back pain during pregnancy

A normal pregnancy brings about several physiological changes in the body. These include mechanical and structural changes to the spine and hips to facilitate pregnancy and childbirth. Changes also include posture, gait (the nature of walk) and total body water content. There are hormonal changes and engorgement of blood vessels around the spine (epidural blood vessels).

The main change in posture is increased forward convexity of the spine (called lumbar lordosis). Most of the weight is thus concentrated low in the pelvis with a protruding abdomen. This leads to low back pain. This also causes a tendency to fall forwards.

Increased total body water means there is collection of fluids in the connective tissues around the vertebral column and pelvis. This increases the laxity around these joints. This fluid retention is also aggravated by hormonal changes of pregnancy. There is a hormone relaxin released during pregnancy. It  softens  the  ligaments around the pelvic joints  and cervix,  possibly by  enhancing fluid  retention  in  these  tissues and this helps in easy childbirth.

Treatment and prevention of back pain during pregnancy

  • Patient education – This is vital. Maintenance of good posture, good methods of rising from sitting or lying position, prevention of awkward lifting etc. should be emphasized.  Patient is advised to stop smoking as this aggravates back pain.
  • Physiotherapy – Physiotherapy in the third trimester may help ease back pain. Other physical treatments include mechanical support for the back for example a wedge shaped pillow for support (Ozzlo pillow), a belt or pelvic girdle etc.
  • Labor pain can be managed appropriately to prevent back pain after childbirth.

Back Pain Research

Back pain affects a significant population worldwide and has a severe impact on a nation’s productivity. Workers worldwide lose a large number of work-days to back pain. Despite this wide prevalence, there are very few sure-fire cures for back pain. Research is constantly taking place worldwide to understand the aetiologies and find therapies to ease back pain.

The National Institute of Neurological Disorders and Stroke (NINDS) and the National Institutes of Health (NIH)

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) have several pain research studies in their laboratories.

The researchers are looking at use of different drugs to effectively treat back pain, in particular, chronic pain that has lasted at least 6 months.

There are yet other studies that compare the different approaches to acute back pain and attempt to find the best approach. These studies in addition compare standard care with pain relievers and hot or cold compresses and physiotherapy with complementary therapies like chiropractic, acupuncture, or massage therapy. There are studies that compare various surgical approaches to back pain as well.

The studies on back pain look at various factors like symptom relief, restoration of function, and patient satisfaction.

Arthritis Research UK Primary Care Centre at Keele University

Arthritis Research UK Primary Care Centre at Keele University is also conducting research on back pain. They have found that a new model of primary care management called stratified primary care management can have significant benefits for patients seeking help from their GP for back pain.

For their approach they group patients into different levels of treatment depending on their level of risk (low, medium or high) for persistent or chronic back pain problems. This stratification helps in more effective treatment of patients. This also reduced healthcare costs because fewer patients ended up coming back through the healthcare system at a later date after being managed effectively at first contact.

Vertebroplasty

Vertebroplasty is a new approach that has been studied extensively. It involves injection of surgical cement into vertebral bodies that have collapsed due to compression fractures to immobilize the spine.

Severe biological response modifier drugs

Like for treatment of arthritis, severe biological response modifier drugs are being tried in chronic back pain. These may provide rapid pain relief and prevent disease progression in back pain.

 

Back Pain Treatment

Back pain treatment varies with the severity, cause and associated factors. Some of the treatments and therapies that may be tried for back pain may be outlined as follows.

Management of acute or short term back pain

This is commonly seen in most individuals with back pain. The pain lasts no longer than six weeks and can be treated with pain relievers that are available over-the-counter or without prescription at a pharmacy and home treatments.

Of the pain relievers Paracetamol (Acetaminophen) is commonly used successfully. Some people find anti-inflammatory drugs such as ibuprofen more effective.

Stronger pain killers like codeine may be taken for more severe pain along with paracetamol.

Those with muscle spasms may be prescribed a muscle relaxant like diazepam along with a pain reliever.

Pain relievers may also be applied as creams, ointments or sprays over the affected area.

Hot and cold compresses

Heat with the use of a hot bath, hot water bottle or heated pad may provide relief from back pain in some individuals. In yet others application of ice packs or a bag of frozen vegetables over the pain may ease the pain. Ice packs, however, should not be applied directly over the back as this may cause cold burns. Some persons also benefit by alternating hot and cold using ice packs and hot compression packs.

Lifestyle changes

  • Sleeping posture – Sleeping posture and mattress may be contributing to the back pain. By changing the sleeping position and/or mattress the pain may be eased or prevented. Patient is advised to sleep on their side and draw their legs up slightly towards their chest and pillow is put between their legs. For those who sleep on their backs, a pillow may be placed under the knees to maintain the normal curve of the lower back.
  • Relaxing muscle tensions – this can be achieved by deep breathing and conscious relaxation of back muscles before retiring to bed each day.
  • Maintaining regular physical activity – Long periods of inactivity is bad for the back. People who remain active are likely to recover more quickly. Earlier those with back pain were advised bed rest. These days they are advised to walk or perform their daily activities to prevent immobility of the back.
  • Weight loss – Being overweight and obese is a risk factor for back pain. Having a healthy and balanced diet along with regular exercise helps in keeping excess weight in check.
  • Reduction of stress
  • Regular exercise and being active and physically fit – This may be achieved by walking, swimming, yoga and pilates. These help in maintaining the flexibility and strength of the back muscles and prevent recurrence of back pain

Management of long term or chronic back pain

Back pain lasting over six weeks is called chronic back pain

  • A more intensive exercise programme is prescribed. This is usually up to eight sessions over a period of up to 12 weeks. It will usually be a group class supervised by a qualified instructor. These exercises help to strengthen the muscles and improve posture. There are aerobic and stretching exercises as well.
  • Manual therapy is prescribed and this includes manipulation, mobilisation and massage. This is performed by chiropractors, osteopaths or physiotherapists. These are usually for up to nine sessions over a period of up to 12 weeks.
  • Acupuncture may be tried as a treatment modality as well. These may include up to 10 sessions over a period of up to 12 weeks.
  • Some patients may suffer from concurrent depression due to their back pain. These patients require antidepressant medications, counselling and cognitive behavioral therapy as well.
  • Surgery is usually only recommended as a treatment option when all else has failed. A common procedure is spinal fusion surgery. This involves fusion or joining up of the joint that is causing pain to prevent it moving.
  • Other therapies include low level laser therapy. In this low energy lasers are focused on the back to reduce the inflammation.
  • Ultrasound waves may also be used to accelerate healing and encourage tissue repair
  • Interferential therapy (IFT) is performed by a device that passes an electrical current through the back to improve healing.
  • Transcutaneous electrical nerve stimulation (TENS) – This is delivered by a machine that provides small electrical pulses to the back through electrodes that are placed on the skin. This helps to reduce the pain signals from the back.
  • Mechanical measures – This includes lumbar supports like cushions, pillows and braces, traction devices for the spine.
  • Drugs – Pain killers and steroids may be directly injected into the affected joints to reduce inflammation and pain.

Warning signs of back pain and when to see the physician

In most cases a few days of rest and adequate mobility may help in recovery from back pain. However, some symptoms may indicate a deeper problem and mandates a visit to the doctor. These symptoms include:

  • Weight loss that is unexplained
  • Fever
  • Swelling and immobility of the back
  • Pain in the limbs
  • Worsening pain at night
  • Numbness of the lower limbs or other parts of the body including genitals
  • Loss of bladder or bowel control
  • Unsteadiness when standing