Lower back pain

Back pain that can happen for no clear reason and which usually settles within a few days or weeks is usually called non-specific low back pain, and is the type of back pain that most people will have at some point in their lives. It means the pain is not due to any specific or underlying disease that can be found but common causes often include a muscle or ligament sprain, a minor problem with a disc between two spinal bones (vertebrae) or a self-limiting problem with one of the joints between two vertebrae called a facet joint.

Because non-specific back pain is sometimes called ‘simple’ back pain, it can be mistaken for very mild pain but although it can be mild it may also be severe too.

What increases the chances of back pain developing?

Certain risk factors increase the chances of developing back pain. These include being overweight or pregnant – the extra weight places additional strain on the back – and smoking although it is not exactly clear why. It may be due to tissue damage in the back caused by smoking or the fact that smokers tend to have unhealthier lifestyles than non-smokers. Other triggers include the long-term use of corticosteroids, stress and associated tension in the back muscles, and depression.

What are the concerning causes of lower back pain?

Less commonly, back pain can be attributed to a long-term cause, such as degenerative arthritis, a slipped disc, or a muscle strain or sprain. Thankfully rare, more serious causes include a fracture after an injury, an infection in the bone or disc, compression of the nerves in the lower back, an inflammatory condition or some cancers and we'll talk you through the signs to look out for.

To diagnose back pain, your doctor will take your medical history and do a physical examination. They may then order other tests, such as X-rays or scans such as Magnetic resonance imaging (MRI scans or Computed tomography (CT scans. They may also suggest having certain blood tests but a thorough medical history and physical exam can usually identify any dangerous conditions.

How is lower back pain treated?

The treatment used for your back pain depends on what kind of pain you have. Acute back pain usually gets better without any treatment, but you may want to take painkillers such as paracetamol or ibuprofen to help ease the pain. Exercise and surgery are not usually used to treat acute back pain.

Painkillers

Chronic back pain is usually treated with painkiller (analgesic) medication – these include over-the-counter drugs such as paracetamol and non-steroidal anti-inflammatory (NSAID) tablets like ibuprofen as well as topical analgesics like pain relief creams and gels that can be rubbed onto the skin over the site of pain.

NSAIDs

Your doctor may prescribe stronger NSAIDs if necessary as well as muscle relaxants and some antidepressants that can be helpful with chronic back pain, although these do not work for every type of back pain.

(Remember - do not give aspirin (acetylsalicylic acid) or aspirin-containing products to anyone 18 years or younger because of the risk of a serious illness called Reye's syndrome. Always take non-steroidal anti-inflammatory drugs (NSAIDs) with food or milk to prevent stomach irritation and do not give NSAIDs to anyone with:

• NSAID-induced asthma

• increased risk of bleeding, such as ulcer disease, a bleeding disorder, if taking blood thinners (anticoagulants), or following surgery, significant trauma or major dental work

• an allergy to NSAIDs.)

Alternative treatments

If back pain is not relieved by medication, some people try complementary and alternative treatments. The most common of these treatments are manipulation such as chiropractic or osteopathic treatment, transcutaneous electrical nerve stimulation (TENS treatment where a small box over the painful area sends mild electrical pulses to nerves to help block pain signals, and acupuncture may also be helpful in some people.

When surgery is required

Most people with chronic back pain do not need surgery and this is only required if other treatments do not work. You may need surgery if you have a slipped disc – here, one or more of the discs that cushion the bones of the spine are damaged and the jelly-like centre of the disc leaks and presses on a spinal nerve causing pain. Other conditions that may require surgery include spinal stenosis where the spinal canal becomes narrow and causes pain, spondylolisthesis – where one or more bones of the spine slip out of place and osteoporosis where weakening of the bones causes them to crumble and occasionally fracture.

If you are being considered for back surgery, your surgeon will consider these points as important reasons to go ahead;

• You are in reasonably good health

• Your back pain significantly affects your quality of life

• If you have leg weakness or numbness

• If you have problems with your bladder or bowels,

• If you have difficulty standing or walking

• If medication and other treatments have been tried and found to be ineffective

Rarely, when back pain is caused by a tumour, a severe infection, or a nerve root problem called cauda equina syndrome, surgery is needed right away to ease the pain and prevent more problems occurring.

If you develop low back pain, it's important to remember that it is very common, usually nothing serious and it usually gets better within a few weeks. However, it can be very painful and difficult to know how to manage until it gets better.

There are things you can do to treat your back pain yourself and the best way to prevent back pain is to keep your back strong and supple. Regular exercise, maintaining good posture and lifting correctly will all help. Other general points that are useful in preventing back pain include losing weight if overweight, wearing flat shoes with cushioned soles, avoiding sudden movements and staying active with regular exercise such as walking and swimming.

Posture tips

How you sit, stand and lie down can have an important effect on your back. When standing, keep as upright as possible with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight. When sitting, make sure you sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor (use a footstool if necessary). Some people find it useful to use a small cushion or rolled-up towel to support the small of the back.

Sleeping tips

Make sure that your mattress is replaced at least every 10 years and that it is firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. If your mattress is too soft, place a firm board (ideally 2cm thick) on top of the base of your bed and under the mattress. Your head should be supported with a pillow, but make sure your neck is not forced up at a steep angle.

Driving tips

Make sure that your lower back is properly supported. Position your wing mirrors correctly so you do not have to twist around and make sure the foot pedals are squarely in front of your feet and that your legs are not at an angle. If you are driving long distances, take regular breaks so that you can stretch your legs.

Exercise tips

Exercise is both an excellent way of preventing back pain and reducing back pain and exercises such as walking or swimming strengthen the muscles that support your back without putting any strain on it. Keeping supple and flexible is also very important so activities such as yoga or pilates can help with this. (It is important that you carry out these activities under the guidance of a properly qualified instructor.)

Some types of exercises that are helpful in keeping the back strong and supple include;

• Wall slides - stand with your back against a wall with your feet shoulder-width apart. Slide down into a crouch so that your knees are bent to about 90 degrees. Count to five and then slide back up the wall. Repeat five times.
• Leg raises - lie flat on your back on the floor. Lift each heel in turn just off the floor while keeping your legs straight. Repeat five times.
• Bottom lifts - lie flat on your back on the floor. Bend your knees so that your feet are flat on the floor. Lift your bottom in the air by tightening your stomach muscles while keeping your back straight. Repeat five times.

Lifting and handling tips

A major cause of back injuries and lower back pain is lifting or handling objects incorrectly. Learning and following correct methods for lifting and handling objects can help prevent this so always think before you lift a heavy object - can you manage the lift? Are there any handling aids you can use? Where is the load going?

• Keep your feet apart, with one leg slightly forward to maintain balance, and then when let your legs do the work - bend your back, knees and hips slightly, but do not stoop or squat. Keep the load as close to your body for as long as possible, with the heaviest end nearest to you.
• Avoid twisting your back or leaning sideways, particularly when your back is bent - your shoulders should be level and facing in the same direction as your hips; turning by moving your feet is better than lifting and twisting at the same time.
• Keep your head up - once you have the load secure, look ahead, not down at the load.
• Know your limits - there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
• Push rather than pull - if you have to move a heavy object across the floor, it is better to push it rather than pull it.
• Distribute the weight evenly - if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.
• Finally - if you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.

Most cases of back pain are nothing to worry about and will improve within a few weeks. Less than 1% of people with low back pain have ‘red flag’ symptoms that mean you should seek medical attention as soon as possible such as:

• if your back pain has not started to improve after 6 weeks

• if your back pain started after a significant fall or accident

• if you have a history of cancer

• if you have sciatica affecting both legs, numbness around your bottom or problems with your bowel or bladder control

• if you are feeling generally unwell with a fever, and no other flu-like symptoms

• if you’ve been taking steroid tablets for several months

• if the pain travels up the back or into the chest

• if you’re aged under 45 and get severe back pain and stiffness first thing in the morning every morning, lasting for 30 minutes or more, and this has persisted for 3 months or more - often movement will make it feel better

• if you’re losing weight for no obvious reason

• If you have any of the above features associated with your back pain your doctor may refer you directly for investigation or to a specialist to identify the cause for your back pain.

If you get back pain and you are under 18 or over 50 years old, or your back pain wakes you up from sleep then you should also request an urgent appointment with your doctor.

When should I see my doctor routinely?

If your back pain has no concerning features, then a routine appointment with your doctor is reasonable. Your doctor may refer you to a physiotherapist for more specialist management or give you stronger painkillers than those available without a prescription. Only rarely does simple low back pain require referral to a specialist for further investigation and treatment.